Healthcare Provider Details

I. General information

NPI: 1831194323
Provider Name (Legal Business Name): LORI A DEBOLD M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2005
Last Update Date: 05/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18111 BROOKHURST ST SUITE 1100
FOUNTAIN VALLEY CA
92708-6728
US

IV. Provider business mailing address

17360 BROOKHURST ST ATTN: MCMF - CREDENTIALING DEPARTMENT
FOUNTAIN VALLEY CA
92708-3720
US

V. Phone/Fax

Practice location:
  • Phone: 714-861-4770
  • Fax: 714-861-4771
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberG66467
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: