Provider Demographics
NPI:1619952538
Name:LOMELINO, MIRIAM ELIZADE (MD)
Entity Type:Individual
Prefix:
First Name:MIRIAM
Middle Name:ELIZADE
Last Name:LOMELINO
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 1:1320 LAS TABLAS RD
Mailing Address - Street 2:SUITE F
Mailing Address - City:TEMPLETON
Mailing Address - State:CA
Mailing Address - Zip Code:93465-9711
Mailing Address - Country:US
Mailing Address - Phone:805-434-0025
Mailing Address - Fax:805-434-0029
Practice Address - Street 1:1320 LAS TABLAS RD
Practice Address - Street 2:SUITE F
Practice Address - City:TEMPLETON
Practice Address - State:CA
Practice Address - Zip Code:93465-9711
Practice Address - Country:US
Practice Address - Phone:805-434-0025
Practice Address - Fax:805-434-0029
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2011-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA72626207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A726260OtherAETNA PIN
CA00A726260Medicaid
CA00A726260OtherBLUE SHIELD PIN
CA00A726260OtherAETNA PIN
CAA72626Medicare PIN
CAH24433Medicare UPIN
CA00A726260Medicaid