1811254329 NPI number — TRAVIS LOIDOLT DO

Table of content: TRAVIS LOIDOLT DO (NPI 1811254329)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811254329 NPI number — TRAVIS LOIDOLT DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LOIDOLT
Provider First Name:
TRAVIS
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1811254329
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/17/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2220 E BIDWELL ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FOLSOM
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95630-3463
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
916-800-4685
Provider Business Mailing Address Fax Number:
916-512-3901

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
584 N SUNRISE AVE STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROSEVILLE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95661-2862
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-800-4685
Provider Business Practice Location Address Fax Number:
916-512-3901
Provider Enumeration Date:
04/20/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207XS0117X , with the licence number:  20A16495 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 20A16495 . This is a "CA MED LICENSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com