Healthcare Provider Details

I. General information

NPI: 1114901246
Provider Name (Legal Business Name): MARY BETH METCALF MD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/01/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2516 STOCKTON BLVD DEPARTMENT OF PEDIATRICS, 3RD FLOOR
SACRAMENTO CA
95817-2208
US

IV. Provider business mailing address

2516 STOCKTON BLVD DEPARTMENT OF PEDIATRICS, 3RD FLOOR
SACRAMENTO CA
95817-2208
US

V. Phone/Fax

Practice location:
  • Phone: 916-734-5387
  • Fax: 916-456-2236
Mailing address:
  • Phone: 916-734-5387
  • Fax: 916-456-2236

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberC33086
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: