Provider Demographics
NPI:1295749547
Name:MOULTRIE-LIZANA, ANGELYN (DO)
Entity type:Individual
Prefix:DR
First Name:ANGELYN
Middle Name:
Last Name:MOULTRIE-LIZANA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:ANGELYN
Other - Middle Name:
Other - Last Name:MOULTRIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:75 REMITTANCE DR DEPT 6008
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60675-6008
Mailing Address - Country:US
Mailing Address - Phone:562-282-1419
Mailing Address - Fax:562-920-4642
Practice Address - Street 1:10251 ARTESIA BLVD
Practice Address - Street 2:
Practice Address - City:BELLFLOWER
Practice Address - State:CA
Practice Address - Zip Code:90706-6719
Practice Address - Country:US
Practice Address - Phone:562-867-8681
Practice Address - Fax:562-925-2721
Is Sole Proprietor?:No
Enumeration Date:2006-07-29
Last Update Date:2014-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A5603207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX56030Medicaid
CA080179414OtherRAILROAD MEDICARE
CA020A56030OtherBLUE SHIELD
CAW20A5603EMedicare ID - Type Unspecified
CAE95989Medicare UPIN
CA00AX56030Medicaid