MEDICARE: DR. LORI A DEBOLD M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	G66467	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	00G664670	OTHER	CA	MEDI CAL

General Provider Information

NPI Number	:	1831194323
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LORI A DEBOLD M.D.

Provider Business Mailing Address
First Line	:	17360 BROOKHURST ST
Second Line	:	ATTN: MCMF - CREDENTIALING DEPARTMENT
City	:	FOUNTAIN VALLEY
State	:	CA
Zip	:	92708-3720
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	18111 BROOKHURST ST
Second Line	:	SUITE 1100
City	:	FOUNTAIN VALLEY
State	:	CA
Zip	:	92708-6728
Country	:	US
Telephone Number	:	714-861-4770
Fax Number	:	714-861-4771

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/20/2005
Last Update Date	:	05/13/2015

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