MEDICARE: DR. MAYA MITCHELL LAND MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	A077171	CA

General Provider Information

NPI Number	:	1619958154
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MAYA MITCHELL LAND MD

Provider Business Mailing Address
First Line	:	401 BICENTENNIAL WAY
Second Line	:
City	:	SANTA ROSA
State	:	CA
Zip	:	95403-2149
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	401 BICENTENNIAL WAY
Second Line	:
City	:	SANTA ROSA
State	:	CA
Zip	:	95403-2149
Country	:	US
Telephone Number	:	707-393-4044
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/10/2005
Last Update Date	:	12/15/2021

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