Provider Demographics
NPI:1235190158
Name:MCCORMICK, MONIQUE C (MD)
Entity Type:Individual
Prefix:
First Name:MONIQUE
Middle Name:C
Last Name:MCCORMICK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MONIQUE
Other - Middle Name:C
Other - Last Name:MATHEWS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:16955 VIA DEL CAMPO
Mailing Address - Street 2:STE 215
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92127-7720
Mailing Address - Country:US
Mailing Address - Phone:858-673-6100
Mailing Address - Fax:858-673-6113
Practice Address - Street 1:555 E VALLEY PKWY
Practice Address - Street 2:
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92025
Practice Address - Country:US
Practice Address - Phone:760-739-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-30
Last Update Date:2010-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA93480207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
H25826Medicare UPIN