Healthcare Provider Details

I. General information

NPI: 1922494061
Provider Name (Legal Business Name): MARY EGUIA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2015
Last Update Date: 02/26/2025
Certification Date: 02/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25828 REDLANDS BLVD
REDLANDS CA
92373-8449
US

IV. Provider business mailing address

FILE # 54701
LOS ANGELES CA
90074-0001
US

V. Phone/Fax

Practice location:
  • Phone: 909-558-6856
  • Fax:
Mailing address:
  • Phone: 909-558-6600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036146878
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberC196414
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: