Healthcare Provider Details

I. General information

NPI: 1265406797
Provider Name (Legal Business Name): DEBRALYNNE ZICKAFOOSE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2006
Last Update Date: 08/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25500 MEDICAL CENTER DRIVE
MURRIETA CA
92562
US

IV. Provider business mailing address

29955 TECHNOLOGY DR 103
MURRIETA CA
92563-2638
US

V. Phone/Fax

Practice location:
  • Phone: 951-200-4601
  • Fax: 951-200-4605
Mailing address:
  • Phone: 951-200-4601
  • Fax: 951-200-4605

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA54704
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: