MEDICARE: DR. JOHN MARK LAWRENCE LAWRENCE JOHN MARK

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	GFE22096	CA

General Provider Information

NPI Number	:	1235436122
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHN MARK LAWRENCE LAWRENCE JOHN MARK

Provider Business Mailing Address
First Line	:	11078 W SUNSET BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90049-3232
Country	:	US
Telephone Number	:	310-476-7901
Fax Number	:

Provider Business Practice Location Address
First Line	:	11078 W SUNSET BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90049-3232
Country	:	US
Telephone Number	:	310-476-7901
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/11/2011
Last Update Date	:	02/11/2011

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