1336240837 NPI number — MARY ROSALIE PENA-PRIDMORE MD

Table of content: MARY ROSALIE PENA-PRIDMORE MD (NPI 1336240837)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336240837 NPI number — MARY ROSALIE PENA-PRIDMORE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PENA-PRIDMORE
Provider First Name:
MARY
Provider Middle Name:
ROSALIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PENA-PRIDMORE
Provider Other First Name:
MARY
Provider Other Middle Name:
ROSALIE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1336240837
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/06/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1114 YUBA ST RM 144
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARYSVILLE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95901-4838
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
530-749-3242
Provider Business Mailing Address Fax Number:
530-741-9274

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9980 LIVE OAK BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LIVE OAK
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95953-2334
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-749-3242
Provider Business Practice Location Address Fax Number:
530-749-3248
Provider Enumeration Date:
09/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  51623 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: C51623 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: EXE70043F , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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