Provider Demographics
NPI:1427141845
Name:CERVA-BUCHOLZ, LORRI JAN (DO)
Entity type:Individual
Prefix:DR
First Name:LORRI
Middle Name:JAN
Last Name:CERVA-BUCHOLZ
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5281 N 99TH AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85305-3105
Mailing Address - Country:US
Mailing Address - Phone:623-516-8252
Mailing Address - Fax:623-516-8253
Practice Address - Street 1:19636 N 27TH AVENUE
Practice Address - Street 2:SUITE 106
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85027
Practice Address - Country:US
Practice Address - Phone:623-516-8252
Practice Address - Fax:623-516-8253
Is Sole Proprietor?:No
Enumeration Date:2006-09-30
Last Update Date:2014-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4313174400000X, 2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ4313OtherSTATE LICENSE
AZ974528Medicaid
AZZ127886Medicare PIN
AZ4313OtherSTATE LICENSE
AZBC9601584OtherDEA
AZ105499Medicare ID - Type Unspecified