Provider Demographics
NPI:1679985675
Name:GALICIA, LORELIE BANARES (MD)
Entity Type:Individual
Prefix:
First Name:LORELIE
Middle Name:BANARES
Last Name:GALICIA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LORELIE
Other - Middle Name:IMPERIO
Other - Last Name:BANARES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1312 ALMA AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-5224
Mailing Address - Country:US
Mailing Address - Phone:213-400-7606
Mailing Address - Fax:
Practice Address - Street 1:3800 DALE RD
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95356-8627
Practice Address - Country:US
Practice Address - Phone:209-557-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-24
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA144978207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty