Healthcare Provider Details

I. General information

NPI: 1942068390
Provider Name (Legal Business Name): MAYRA CAMILLE REPETTO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/11/2024
Last Update Date: 05/20/2026
Certification Date: 05/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 PARNASSUS AVE
SAN FRANCISCO CA
94143-2204
US

IV. Provider business mailing address

625 SHADOW LN
LAS VEGAS NV
89106-4118
US

V. Phone/Fax

Practice location:
  • Phone: 415-476-1000
  • Fax:
Mailing address:
  • Phone: 801-657-2280
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberPTL20567
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: