Provider Demographics
NPI:1023065992
Name:LOWELL P THEARD MD INC
Entity type:Organization
Organization Name:LOWELL P THEARD MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LOWELL
Authorized Official - Middle Name:P
Authorized Official - Last Name:THEARD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-838-6801
Mailing Address - Street 1:4206 DON TAPIA PL
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90008-4236
Mailing Address - Country:US
Mailing Address - Phone:310-838-6801
Mailing Address - Fax:310-838-5385
Practice Address - Street 1:3831 HUGHES AVE
Practice Address - Street 2:705
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90232-2751
Practice Address - Country:US
Practice Address - Phone:310-838-6801
Practice Address - Fax:310-838-5385
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-27
Last Update Date:2013-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG37108207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1023065992Medicaid
CAEF954AMedicare PIN