1336215102 NPI number — DR. LAWRENCE TODD WOODBURN PH.D.

Table of content: DR. LAWRENCE TODD WOODBURN PH.D. (NPI 1336215102)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336215102 NPI number — DR. LAWRENCE TODD WOODBURN PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WOODBURN
Provider First Name:
LAWRENCE
Provider Middle Name:
TODD
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PH.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1336215102
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5670 DOLPHIN PL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LA JOLLA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92037-7517
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
760-434-2242
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9255 TOWNE CENTRE DR
Provider Second Line Business Practice Location Address:
SUITE 370
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92121-3033
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-434-2242
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X , with the licence number:  PSY 5312 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00PL53120 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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