Provider Demographics
NPI:1194751537
Name:LAUDER, PATRICIO L (MD)
Entity type:Individual
Prefix:
First Name:PATRICIO
Middle Name:L
Last Name:LAUDER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:PATRICIO
Other - Middle Name:L
Other - Last Name:LAUDER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:210 N TUSTIN AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-3807
Mailing Address - Country:US
Mailing Address - Phone:714-347-1010
Mailing Address - Fax:714-647-1245
Practice Address - Street 1:975 S FAIRMONT AVE
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95240-5118
Practice Address - Country:US
Practice Address - Phone:408-500-1186
Practice Address - Fax:408-847-1460
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-25
Last Update Date:2013-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA64160207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A641601Medicaid
CAH17733Medicare UPIN
CA00A641600Medicare PIN