Provider Demographics
NPI:1316970171
Name:URADOMO, LANCE T (MD)
Entity type:Individual
Prefix:DR
First Name:LANCE
Middle Name:T
Last Name:URADOMO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 512185
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90051-0185
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1000 FIVEPOINT
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92618-2377
Practice Address - Country:US
Practice Address - Phone:949-671-4673
Practice Address - Fax:949-671-4329
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2022-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC180512207RG0100X
MDD64182207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD891075-01OtherBLUE CROSS/BLUE SHIELD
MD410913900Medicaid
MDO172Medicare PIN
MDP00427013Medicare PIN
MD891075-01OtherBLUE CROSS/BLUE SHIELD