Basic Information
| Provider Information | |||||||||
| NPI: | 1023046547 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LAWRENCE | ||||||||
| FirstName: | TRACY | ||||||||
| MiddleName: | DEBRA | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 31309 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900310309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3234425100 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1520 SAN PABLO ST | ||||||||
| Address2: | SUITE 1000 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900335310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3234425100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2006 | ||||||||
| LastUpdateDate: | 03/10/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | A73940 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 00A739400 | 01 | CA | BLUE SHIELD | OTHER | CE1617 | 01 | CA | GROUP RAILROAD MEDICARE | OTHER | P00407895 | 01 | CA | RAILROAD MEDICARE | OTHER | W11675 | 01 | CA | GROUP MEDICARE PIN | OTHER | 1356390009 | 01 | CA | GROUP NPI | OTHER | GR0016910 | 01 | CA | GROUP MEDICAID PIN | OTHER | 00A739400 | 05 | CA | MEDICAID | 00A739400197 | 01 | CA | CAL OPTIMA | OTHER |