Healthcare Provider Details

I. General information

NPI: 1073685814
Provider Name (Legal Business Name): LINDA WASHINGTON FORY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LINDA KAREN WASHINGTON

II. Dates (important events)

Enumeration Date: 11/15/2006
Last Update Date: 10/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 W CENTRAL AVE STE 201
LOMPOC CA
93436-2807
US

IV. Provider business mailing address

2050 S BLOSSER RD
SANTA MARIA CA
93458-7310
US

V. Phone/Fax

Practice location:
  • Phone: 372-080-5737
  • Fax: 805-737-1772
Mailing address:
  • Phone: 805-361-8028
  • Fax: 805-361-8097

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD60481573
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA73101
License Number StateCA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier00A731010
Identifier TypeMEDICAID
Identifier StateCA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: