Provider Demographics
NPI:1003922329
Name:KEOHANE, MARY E (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:E
Last Name:KEOHANE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3301 C ST
Mailing Address - Street 2:SUITE 200E
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95816-3300
Mailing Address - Country:US
Mailing Address - Phone:916-447-6267
Mailing Address - Fax:916-447-0621
Practice Address - Street 1:3301 C ST
Practice Address - Street 2:SUITE 200E
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816-3300
Practice Address - Country:US
Practice Address - Phone:916-447-6267
Practice Address - Fax:916-447-0621
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2008-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC50535174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C505350Medicaid
CA00C505350Medicaid
CA00C505351Medicare UPIN
CA00C505350Medicare UPIN