Healthcare Provider Details

I. General information

NPI: 1326128158
Provider Name (Legal Business Name): MAINSTREET MEDICAL PRACTICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/16/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 MAIN STREET
HALF MOON BAY CA
94019
US

IV. Provider business mailing address

725 MAIN STREET
HALF MOON BAY CA
94019
US

V. Phone/Fax

Practice location:
  • Phone: 650-726-1200
  • Fax: 650-726-1235
Mailing address:
  • Phone: 650-726-1200
  • Fax: 650-726-1235

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20A4678
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberG31635
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20A62160
License Number StateCA

VIII. Authorized Official

Name: DR. DEBORAH B PENROSE
Title or Position: DOCTOR
Credential: DO
Phone: 650-726-1200