Provider Demographics
NPI:1083621379
Name:PRESIDENT, MARIE CAROL (MD)
Entity Type:Individual
Prefix:DR
First Name:MARIE
Middle Name:CAROL
Last Name:PRESIDENT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:3400 DATA DR
Mailing Address - Street 2:ATTN: CREDENTIALING/PAYER ENROLLMENT
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95670-7956
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1301 SHOREWAY RD STE 100
Practice Address - Street 2:
Practice Address - City:BELMONT
Practice Address - State:CA
Practice Address - Zip Code:94002-4110
Practice Address - Country:US
Practice Address - Phone:650-596-7000
Practice Address - Fax:650-596-7093
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2019-07-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG078841207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG11041Medicare UPIN
ZZZ16205ZMedicare ID - Type Unspecified