Basic Information
| Provider Information | |||||||||
| NPI: | 1336103076 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WELLS | ||||||||
| FirstName: | LAWRENCE | ||||||||
| MiddleName: | EDWARD | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 80116 | ||||||||
| Address2: | |||||||||
| City: | CITY OF INDUSTRY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917168116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8007494560 | ||||||||
| FaxNumber: | 4057494561 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 S BUENA VISTA ST | ||||||||
| Address2: | |||||||||
| City: | BURBANK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 915054809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8188435111 | ||||||||
| FaxNumber: | 4057494561 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2006 | ||||||||
| LastUpdateDate: | 12/01/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | A49234 | CA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00A492340 | 05 | CA | MEDICAID | A49234 | 01 | BLUE CROSS | OTHER | 00A492340 | 01 | BLUE SHIELD | OTHER |