Provider Demographics
NPI:1952325532
Name:LORI J IZABAL M D A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:LORI J IZABAL M D A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PENNY
Authorized Official - Middle Name:E
Authorized Official - Last Name:HILL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-640-4455
Mailing Address - Street 1:360 SAN MIGUEL DR
Mailing Address - Street 2:SUITE 206
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-7853
Mailing Address - Country:US
Mailing Address - Phone:949-640-4455
Mailing Address - Fax:949-640-4456
Practice Address - Street 1:360 SAN MIGUEL DR
Practice Address - Street 2:SUITE 206
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-7853
Practice Address - Country:US
Practice Address - Phone:949-640-4455
Practice Address - Fax:949-640-4456
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-27
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA061528261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW19912Medicare PIN