Healthcare Provider Details

I. General information

NPI: 1053337923
Provider Name (Legal Business Name): LORI J. WYNSTOCK, M.D.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 03/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 BELLEFONTAINE ST #203
PASADENA CA
91105-3132
US

IV. Provider business mailing address

PO BOX 1430
MONROVIA CA
91017-1430
US

V. Phone/Fax

Practice location:
  • Phone: 626-793-6113
  • Fax: 626-793-8013
Mailing address:
  • Phone: 626-256-6010
  • Fax: 626-256-6070

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA63397
License Number StateCA

VIII. Authorized Official

Name: LORI J. WYNSTOCK
Title or Position: PRESIDENT
Credential: M.D.
Phone: 626-793-6113