Healthcare Provider Details

I. General information

NPI: 1770783847
Provider Name (Legal Business Name): MARY ELLEN MCCORMICK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2007
Last Update Date: 07/18/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27867 SMYTH DR #100
VALENCIA CA
91355-6059
US

IV. Provider business mailing address

27867 SMYTH DR #100
VALENCIA CA
91355-6059
US

V. Phone/Fax

Practice location:
  • Phone: 661-294-2229
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License NumberA95179
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: