Provider Demographics
NPI:1164628384
Name:DATTOMA, LUCIA LOREDANA (MD)
Entity Type:Individual
Prefix:
First Name:LUCIA
Middle Name:LOREDANA
Last Name:DATTOMA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5767 W CENTURY BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-5631
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2655 1ST ST STE 360
Practice Address - Street 2:
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93065-1581
Practice Address - Country:US
Practice Address - Phone:805-583-7640
Practice Address - Fax:805-583-7641
Is Sole Proprietor?:No
Enumeration Date:2007-06-25
Last Update Date:2019-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA87809207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A878090Medicaid
CA00A878090Medicaid
CAWA87809AMedicare PIN