MEDICARE: MARIA LOURDES S MARA MD - A MEDICAL CORP

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	261Q00000X	Clinic/Center	A51864

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1679890644
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARIA LOURDES S MARA MD - A MEDICAL CORP

Provider Business Mailing Address
First Line	:	2939 ALTA VIEW DR STE J
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92139-3394
Country	:	US
Telephone Number	:	619-475-5411
Fax Number	:	619-475-1839

Provider Business Practice Location Address
First Line	:	2939 ALTA VIEW DR STE J
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92139-3394
Country	:	US
Telephone Number	:	619-475-5411
Fax Number	:	619-475-1839

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. MARIA LOURDES DE LOS SANTOS MARA
Credential	:	M.D.
Telephone Number	:	619-475-5411

Provider Enumeration Date	:	04/29/2010
Last Update Date	:	03/09/2011

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