Healthcare Provider Details

I. General information

NPI: 1720277288
Provider Name (Legal Business Name): MARY JOAN D GIDOR MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/22/2007
Last Update Date: 06/23/2022
Certification Date: 06/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50249 CESAR CHAVEZ ST STE K
COACHELLA CA
92236-1530
US

IV. Provider business mailing address

50249 CESAR CHAVEZ ST STE K
COACHELLA CA
92236-1530
US

V. Phone/Fax

Practice location:
  • Phone: 760-393-0555
  • Fax: 760-393-0522
Mailing address:
  • Phone: 760-393-0555
  • Fax: 760-393-0522

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME113398
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD447147
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberC177140
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: