Healthcare Provider Details

I. General information

NPI: 1801089578
Provider Name (Legal Business Name): LIBERTY GRACE LOWE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2007
Last Update Date: 11/29/2021
Certification Date: 11/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 W CIVIC CENTER DR STE 100
SANTA ANA CA
92701-4079
US

IV. Provider business mailing address

28311 CAMINO LA RONDA
SAN JUAN CAPISTRANO CA
92675-5808
US

V. Phone/Fax

Practice location:
  • Phone: 714-796-5100
  • Fax:
Mailing address:
  • Phone: 310-614-3349
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA93401
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: