Provider Demographics
NPI:1104070010
Name:WILLISON, LAWRENCE DAVID IV (MD, PHD)
Entity type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:DAVID
Last Name:WILLISON
Suffix:IV
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:760 WESTWOOD PLZ
Mailing Address - Street 2:SUITE C8-551
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024-5055
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:760 WESTWOOD PLZ
Practice Address - Street 2:SUITE C8-225, BOX 951759
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90024-5055
Practice Address - Country:US
Practice Address - Phone:310-825-0548
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-05
Last Update Date:2011-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA1117762084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program