Basic Information
Provider Information
NPI: 1003150434
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: LAWRENCE
FirstName: DEREK
MiddleName:  
NamePrefix: DR.
NameSuffix:  
Credential: N.D.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 560 CARLSBAD VILLAGE DR
Address2: 202C
City: CARLSBAD
State: CA
PostalCode: 920082391
CountryCode: US
TelephoneNumber: 7603064842
FaxNumber: 7603064844
Practice Location
Address1: 560 CARLSBAD VILLAGE DR
Address2: 202C
City: CARLSBAD
State: CA
PostalCode: 920082391
CountryCode: US
TelephoneNumber: 7603064842
FaxNumber: 7603064844
Other Information
ProviderEnumerationDate: 11/26/2012
LastUpdateDate: 07/19/2015
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
175F00000XND-560CAY Other Service ProvidersNaturopath 

No ID Information.


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