Provider Demographics
NPI:1053337923
Name:LORI J. WYNSTOCK, M.D.
Entity type:Organization
Organization Name:LORI J. WYNSTOCK, M.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LORI
Authorized Official - Middle Name:J
Authorized Official - Last Name:WYNSTOCK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-793-6113
Mailing Address - Street 1:PO BOX 1430
Mailing Address - Street 2:
Mailing Address - City:MONROVIA
Mailing Address - State:CA
Mailing Address - Zip Code:91017-1430
Mailing Address - Country:US
Mailing Address - Phone:626-256-6010
Mailing Address - Fax:626-256-6070
Practice Address - Street 1:50 BELLEFONTAINE ST
Practice Address - Street 2:#203
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-3132
Practice Address - Country:US
Practice Address - Phone:626-793-6113
Practice Address - Fax:626-793-8013
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-14
Last Update Date:2008-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA63397207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP00069309OtherRAILROAD MEDICARE
CAG90524Medicare UPIN