Healthcare Provider Details

I. General information

NPI: 1811254329
Provider Name (Legal Business Name): TRAVIS LOIDOLT DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2012
Last Update Date: 02/17/2023
Certification Date: 02/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

584 N SUNRISE AVE STE 100
ROSEVILLE CA
95661-2862
US

IV. Provider business mailing address

2220 E BIDWELL ST
FOLSOM CA
95630-3463
US

V. Phone/Fax

Practice location:
  • Phone: 916-800-4685
  • Fax: 916-512-3901
Mailing address:
  • Phone: 916-800-4685
  • Fax: 916-512-3901

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number20A16495
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: