Basic Information
Provider Information | |||||||||
NPI: | 1477096782 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | STODDARD LYNDSEY | ||||||||
FirstName: | MARIE | ||||||||
MiddleName: | ALEXIA | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | STODDARD | ||||||||
OtherFirstName: | MARIE | ||||||||
OtherMiddleName: | ALEXIA | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 2285 CORPORATE CIR STE 200 | ||||||||
Address2: |   | ||||||||
City: | HENDERSON | ||||||||
State: | NV | ||||||||
PostalCode: | 890747759 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7023602763 | ||||||||
FaxNumber: | 9497832880 | ||||||||
Practice Location | |||||||||
Address1: | 4244 RIVERWALK PKWY STE 170 | ||||||||
Address2: |   | ||||||||
City: | RIVERSIDE | ||||||||
State: | CA | ||||||||
PostalCode: | 925053373 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9517367432 | ||||||||
FaxNumber: | 9517367751 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/18/2016 | ||||||||
LastUpdateDate: | 08/13/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/13/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | 171336 | CA | Y |   | Allopathic & Osteopathic Physicians | Dermatology |   |
No ID Information.