Healthcare Provider Details

I. General information

NPI: 1386642783
Provider Name (Legal Business Name): MARY JO VITA URSO D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2005
Last Update Date: 08/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1515 W FLORIDA AVE
HEMET CA
92543
US

IV. Provider business mailing address

1515 W FLORIDA AVE
HEMET CA
92543-3817
US

V. Phone/Fax

Practice location:
  • Phone: 951-929-8400
  • Fax: 951-929-8411
Mailing address:
  • Phone: 951-929-8400
  • Fax: 951-929-8411

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number3696
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number20A8265
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: