Provider Demographics
NPI:1679890644
Name:MARIA LOURDES S MARA MD - A MEDICAL CORP
Entity type:Organization
Organization Name:MARIA LOURDES S MARA MD - A MEDICAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIA LOURDES
Authorized Official - Middle Name:DE LOS SANTOS
Authorized Official - Last Name:MARA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:619-475-5411
Mailing Address - Street 1:2939 ALTA VIEW DR STE J
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92139-3394
Mailing Address - Country:US
Mailing Address - Phone:619-475-5411
Mailing Address - Fax:619-475-1839
Practice Address - Street 1:2939 ALTA VIEW DR STE J
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92139-3394
Practice Address - Country:US
Practice Address - Phone:619-475-5411
Practice Address - Fax:619-475-1839
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-29
Last Update Date:2011-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
A51864261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A518642Medicaid
CAF96657Medicare UPIN
A51864AMedicare PIN
CADJ250AMedicare PIN