Provider Demographics
NPI:1093811176
Name:MA, AYEMOETHU (MD)
Entity Type:Individual
Prefix:
First Name:AYEMOETHU
Middle Name:
Last Name:MA
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 1:10790 RANCHO BERNARDO RD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92127-5705
Mailing Address - Country:US
Mailing Address - Phone:858-554-8984
Mailing Address - Fax:858-554-5055
Practice Address - Street 1:10666 N TORREY PINES RD # MS 213
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-1092
Practice Address - Country:US
Practice Address - Phone:858-554-8984
Practice Address - Fax:858-554-5055
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2018-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY245256208600000X
CAC139328208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPENDINGMedicare UPIN