Provider Demographics
NPI:1710910336
Name:TUMBAGA-NOTARIO, LILY (MD)
Entity Type:Individual
Prefix:
First Name:LILY
Middle Name:
Last Name:TUMBAGA-NOTARIO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LILY
Other - Middle Name:
Other - Last Name:NOTARIO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:600 COFFEE RD
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-4201
Mailing Address - Country:US
Mailing Address - Phone:209-521-6097
Mailing Address - Fax:
Practice Address - Street 1:999 S FAIRMONT AVE
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95240-5100
Practice Address - Country:US
Practice Address - Phone:209-366-2001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA64410207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A644102Medicare PIN