Healthcare Provider Details

I. General information

NPI: 1053881987
Provider Name (Legal Business Name): MARYAM ESHO, M.D., A PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2018
Last Update Date: 12/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1729 N OLIVE AVE STE 7
TURLOCK CA
95382-2501
US

IV. Provider business mailing address

1729 N OLIVE AVE STE 7
TURLOCK CA
95382-2501
US

V. Phone/Fax

Practice location:
  • Phone: 209-573-3333
  • Fax: 209-844-0334
Mailing address:
  • Phone: 209-668-6900
  • Fax: 209-668-6903

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: GINA WALLACE
Title or Position: AGENT
Credential:
Phone: 209-573-3333