Basic Information
Provider Information | |||||||||
NPI: | 1942395983 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LIN | ||||||||
FirstName: | INIL | ||||||||
MiddleName: | LISA | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6261 STANTON AVE | ||||||||
Address2: |   | ||||||||
City: | BUENA PARK | ||||||||
State: | CA | ||||||||
PostalCode: | 906212436 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7147394325 | ||||||||
FaxNumber: | 7144521679 | ||||||||
Practice Location | |||||||||
Address1: | 6261 STANTON AVE | ||||||||
Address2: |   | ||||||||
City: | BUENA PARK | ||||||||
State: | CA | ||||||||
PostalCode: | 906212436 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7147394325 | ||||||||
FaxNumber: | 7144521679 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/04/2006 | ||||||||
LastUpdateDate: | 12/28/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | A84233 | CA | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | WA84233A | 01 | CA | PPIN | OTHER | W11614 | 01 | CA | GROUP ID | OTHER |