Provider Demographics
NPI:1023184132
Name:COLOMA, MARA (MD)
Entity Type:Individual
Prefix:DR
First Name:MARA
Middle Name:
Last Name:COLOMA
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:PO BOX 10432
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90213-3432
Mailing Address - Country:US
Mailing Address - Phone:213-637-2530
Mailing Address - Fax:213-384-3373
Practice Address - Street 1:6347 PACIFIC BLVD
Practice Address - Street 2:
Practice Address - City:HUNTINGTON PARK
Practice Address - State:CA
Practice Address - Zip Code:90255-4101
Practice Address - Country:US
Practice Address - Phone:323-583-8383
Practice Address - Fax:323-583-8399
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2010-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA45090208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A450900Medicaid
CA00A450900Medicaid
F45640Medicare UPIN