Healthcare Provider Details

I. General information

NPI: 1306838909
Provider Name (Legal Business Name): MARY M KOUMAS D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2005
Last Update Date: 12/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24401 MUIRLANDS BLVD SUITE #A
LAKE FOREST CA
92630-3948
US

IV. Provider business mailing address

24401 MUIRLANDS BLVD SUITE #A
LAKE FOREST CA
92630-3948
US

V. Phone/Fax

Practice location:
  • Phone: 949-770-1950
  • Fax: 949-770-8599
Mailing address:
  • Phone: 949-770-1950
  • Fax: 949-770-8599

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20A4402
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: