Healthcare Provider Details

I. General information

NPI: 1407806250
Provider Name (Legal Business Name): MARTA SAN LUCIANO PALENZUELA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2006
Last Update Date: 05/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1635 DIVISADERO ST SUITE 520-530
SAN FRANCISCO CA
94115-3036
US

IV. Provider business mailing address

1635 DIVISADERO ST SUITE 520-530
SAN FRANCISCO CA
94115-3036
US

V. Phone/Fax

Practice location:
  • Phone: 415-353-2311
  • Fax: 415-353-9060
Mailing address:
  • Phone: 415-353-2311
  • Fax: 415-353-9060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberA119098
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number003600
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: