Healthcare Provider Details

I. General information

NPI: 1679985675
Provider Name (Legal Business Name): LORELIE BANARES GALICIA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LORELIE IMPERIO BANARES M.D.

II. Dates (important events)

Enumeration Date: 05/24/2014
Last Update Date: 02/11/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3800 DALE RD
MODESTO CA
95356-8627
US

IV. Provider business mailing address

1312 ALMA AVE APT 1
MODESTO CA
95350-5224
US

V. Phone/Fax

Practice location:
  • Phone: 209-557-1000
  • Fax:
Mailing address:
  • Phone: 213-400-7606
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA144978
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: