Healthcare Provider Details

I. General information

NPI: 1215920038
Provider Name (Legal Business Name): MARY THERESE KERRIGAN M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2005
Last Update Date: 11/29/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1188 N EUCLID ST
ANAHEIM CA
92801-1900
US

IV. Provider business mailing address

1188 N EUCLID ST
ANAHEIM CA
92801-1900
US

V. Phone/Fax

Practice location:
  • Phone: 888-505-0043
  • Fax: 626-405-6768
Mailing address:
  • Phone: 888-505-0043
  • Fax: 626-405-6768

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA 55547
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: