Provider Demographics
NPI:1184828964
Name:REGIS, LOUELLA M (MD)
Entity Type:Individual
Prefix:
First Name:LOUELLA
Middle Name:M
Last Name:REGIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARIA
Other - Middle Name:AGUSTINA
Other - Last Name:REGIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 649
Mailing Address - Street 2:
Mailing Address - City:FORT DEFIANCE
Mailing Address - State:AZ
Mailing Address - Zip Code:86504-0649
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:911 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:CALISTOGA
Practice Address - State:CA
Practice Address - Zip Code:94515-1433
Practice Address - Country:US
Practice Address - Phone:707-709-2308
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-13
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301083835207Q00000X
HIMD-15277207Q00000X
CAA101548207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI634825-02Medicaid
HI0000286773OtherHMSA BILLING NUMBER
CA00A1015480Medicaid
HI0000286773OtherHMSA BILLING NUMBER
CA00A1015480Medicaid
CABA076VMedicare PIN
CABA076WMedicare PIN
HI634825-02Medicaid
CABA076SMedicare PIN
CABA076ZMedicare PIN
CABA076TMedicare PIN
CABA076UMedicare PIN