Provider Demographics
NPI:1528036910
Name:VANYO, LORI LEE (MD)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:LEE
Last Name:VANYO
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 1:250 W BONITA AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-1863
Mailing Address - Country:US
Mailing Address - Phone:909-766-1600
Mailing Address - Fax:909-766-1601
Practice Address - Street 1:250 W BONITA AVE STE 100
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767
Practice Address - Country:US
Practice Address - Phone:909-766-1600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-10
Last Update Date:2018-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA55042208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A550420Medicaid
H01885Medicare UPIN
CAH01885Medicare ID - Type Unspecified