Healthcare Provider Details

I. General information

NPI: 1508844796
Provider Name (Legal Business Name): GEORGIA CAROL ALLEN DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/06/2006
Last Update Date: 06/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

365 TUOLUMNE ST
VALLEJO CA
94590-5700
US

IV. Provider business mailing address

1310 CLUB DR
VALLEJO CA
94592-1187
US

V. Phone/Fax

Practice location:
  • Phone: 707-553-5509
  • Fax: 707-553-5658
Mailing address:
  • Phone: 707-638-5232
  • Fax: 707-638-5255

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberK7497
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number20A6109
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: