Healthcare Provider Details

I. General information

NPI: 1871576603
Provider Name (Legal Business Name): JANET PHYLLIS LORD MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/25/2005
Last Update Date: 11/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3031 TELEGRAPH AVE STE 241
BERKELEY CA
94705-2051
US

IV. Provider business mailing address

3031 TELEGRAPH AVE STE 241
BERKELEY CA
94705-2051
US

V. Phone/Fax

Practice location:
  • Phone: 510-549-2037
  • Fax: 510-549-2690
Mailing address:
  • Phone: 510-549-2037
  • Fax: 510-549-2690

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License NumberG40776
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License NumberG40776
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: