Healthcare Provider Details

I. General information

NPI: 1316970171
Provider Name (Legal Business Name): LANCE T. URADOMO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 07/19/2022
Certification Date: 07/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 FIVEPOINT
IRVINE CA
92618-2377
US

IV. Provider business mailing address

PO BOX 512185
LOS ANGELES CA
90051-0185
US

V. Phone/Fax

Practice location:
  • Phone: 949-671-4673
  • Fax: 949-671-4329
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberC180512
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberD64182
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: