Provider Demographics
NPI:1306838909
Name:KOUMAS, MARY M (DO)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:M
Last Name:KOUMAS
Suffix:
Gender:F
Credentials:DO
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Mailing Address - Street 1:24401 MUIRLANDS BLVD
Mailing Address - Street 2:SUITE #A
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92630-3948
Mailing Address - Country:US
Mailing Address - Phone:949-770-1950
Mailing Address - Fax:949-770-8599
Practice Address - Street 1:24401 MUIRLANDS BLVD
Practice Address - Street 2:SUITE #A
Practice Address - City:LAKE FOREST
Practice Address - State:CA
Practice Address - Zip Code:92630-3948
Practice Address - Country:US
Practice Address - Phone:949-770-1950
Practice Address - Fax:949-770-8599
Is Sole Proprietor?:No
Enumeration Date:2005-08-19
Last Update Date:2008-12-09
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CA20A4402207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC64510Medicare UPIN