Basic Information
| Provider Information | |||||||||
| NPI: | 1295749547 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOULTRIE-LIZANA | ||||||||
| FirstName: | ANGELYN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MOULTRIE | ||||||||
| OtherFirstName: | ANGELYN | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | D.O.. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 75 REMITTANCE DR DEPT 6008 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606756008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5622821419 | ||||||||
| FaxNumber: | 5629204642 | ||||||||
| Practice Location | |||||||||
| Address1: | 10251 ARTESIA BLVD | ||||||||
| Address2: | |||||||||
| City: | BELLFLOWER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 907066719 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5628678681 | ||||||||
| FaxNumber: | 5629252721 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2006 | ||||||||
| LastUpdateDate: | 03/27/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 20A5603 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00AX56030 | 05 | CA | MEDICAID | 080179414 | 01 | CA | RAILROAD MEDICARE | OTHER | 020A56030 | 01 | CA | BLUE SHIELD | OTHER |