Provider Demographics
NPI:1255411401
Name:SHOLLY, CYNTHIA H (MD)
Entity type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:H
Last Name:SHOLLY
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:PO BOX 54559
Mailing Address - Street 2:UCI DEPARTMENT OF PEDIATRICS
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90054-0559
Mailing Address - Country:US
Mailing Address - Phone:714-456-6369
Mailing Address - Fax:
Practice Address - Street 1:UCI MEDICAL CENTER
Practice Address - Street 2:101 THE CITY DRIVE SOUTH
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868
Practice Address - Country:US
Practice Address - Phone:714-456-8978
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2019-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA000000G57317208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWG57317BMedicare PIN