Basic Information
| Provider Information | |||||||||
| NPI: | 1619159639 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BURCHETT | ||||||||
| FirstName: | LAWRENCE | ||||||||
| MiddleName: | RAY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | IV | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 50 DOUGLAS DR | ||||||||
| Address2: | SUITE 391 | ||||||||
| City: | MARTINEZ | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945534098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9259575409 | ||||||||
| FaxNumber: | 9259575401 | ||||||||
| Practice Location | |||||||||
| Address1: | 2500 ALHAMBRA AVE | ||||||||
| Address2: | |||||||||
| City: | MARTINEZ | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945533156 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9253705110 | ||||||||
| FaxNumber: | 9253705142 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2007 | ||||||||
| LastUpdateDate: | 02/09/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | A101752 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207P00000X | A101752 | CA | N | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1619159639 | 05 | CA | MEDICAID |