Provider Demographics
NPI:1265406797
Name:ZICKAFOOSE, DEBRALYNNE (MD)
Entity type:Individual
Prefix:DR
First Name:DEBRALYNNE
Middle Name:
Last Name:ZICKAFOOSE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:29955 TECHNOLOGY DR 103
Mailing Address - Street 2:
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92563-2638
Mailing Address - Country:US
Mailing Address - Phone:951-200-4601
Mailing Address - Fax:951-200-4605
Practice Address - Street 1:25500 MEDICAL CENTER DRIVE
Practice Address - Street 2:
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92562
Practice Address - Country:US
Practice Address - Phone:951-200-4601
Practice Address - Fax:951-200-4605
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2015-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA54704207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G66192Medicare UPIN
CS695YMedicare PIN