Healthcare Provider Details

I. General information

NPI: 1457357618
Provider Name (Legal Business Name): JUDY D MAMACLAY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2005
Last Update Date: 03/15/2025
Certification Date: 03/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4131 GEARY BLVD
SAN FRANCISCO CA
94118-3101
US

IV. Provider business mailing address

4131 GEARY BLVD
SAN FRANCISCO CA
94118-3101
US

V. Phone/Fax

Practice location:
  • Phone: 415-418-9114
  • Fax:
Mailing address:
  • Phone: 415-418-9114
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number040859
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: