Healthcare Provider Details

I. General information

NPI: 1154516599
Provider Name (Legal Business Name): MARIA R CAPETANAKIS DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2007
Last Update Date: 02/04/2025
Certification Date: 02/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4150 REGENTS PARK ROW STE 355
LA JOLLA CA
92037-9102
US

IV. Provider business mailing address

455 E COLUMBIA ST STE 201
LONG BEACH CA
90806-1620
US

V. Phone/Fax

Practice location:
  • Phone: 858-457-2043
  • Fax: 858-457-2092
Mailing address:
  • Phone: 562-933-0400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number20A8190
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: