Provider Demographics
NPI:1306852082
Name:FODOR, LASZLO B (MD)
Entity Type:Individual
Prefix:
First Name:LASZLO
Middle Name:B
Last Name:FODOR
Suffix:
Gender:M
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:PO BOX 15498
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95851
Mailing Address - Country:US
Mailing Address - Phone:559-455-4000
Mailing Address - Fax:559-455-4007
Practice Address - Street 1:1121 W VINE STREET
Practice Address - Street 2:SUITE 15
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95240
Practice Address - Country:US
Practice Address - Phone:209-334-4416
Practice Address - Fax:209-371-0119
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2008-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG230662085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G230660Medicaid
CA00G230664Medicare PIN
CA00G2306611Medicare PIN
CA00G230669Medicare PIN
CA00G230666Medicare PIN
CA00G230665Medicare PIN
CA00G230667Medicare PIN
CAA41832Medicare UPIN
CA00G230668Medicare PIN
CA300116086Medicare PIN
CA00G2306610Medicare PIN
CA00G230660Medicare PIN