Provider Demographics
NPI:1235364258
Name:SUMITHRA, MARY JESSIE (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:JESSIE
Last Name:SUMITHRA
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 1:501 6TH ST
Mailing Address - Street 2:APT 12-J
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11215-3671
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4125 BANGS AVE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95356-8713
Practice Address - Country:US
Practice Address - Phone:209-557-1630
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-19
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA105261208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics