1972628485 NPI number — MARY E WHITLOCK FITHIAN MD

Table of content: MARY E WHITLOCK FITHIAN MD (NPI 1972628485)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972628485 NPI number — MARY E WHITLOCK FITHIAN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WHITLOCK FITHIAN
Provider First Name:
MARY
Provider Middle Name:
E
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:
WHITLOCK
Provider Other First Name:
MARY
Provider Other Middle Name:
E
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:
1972628485
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/28/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
393 E WALNUT ST
Provider Second Line Business Mailing Address:
3RD FLOOR PHR SYSTEMS
Provider Business Mailing Address City Name:
PASADENA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91188-0001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
626-405-3640
Provider Business Mailing Address Fax Number:
626-405-6768

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4405 VANDEVER AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92120-3315
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-528-5000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/21/2007

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: 207RG0100X , with the licence number:  G68351 , 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: 00G683510 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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