Provider Demographics
NPI:1306853403
Name:ENO, MARY (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:ENO
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 1:604 ROSE AVE
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:CA
Mailing Address - Zip Code:90291-2767
Mailing Address - Country:US
Mailing Address - Phone:310-664-7600
Mailing Address - Fax:
Practice Address - Street 1:604 ROSE AVE
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:CA
Practice Address - Zip Code:90291-2767
Practice Address - Country:US
Practice Address - Phone:310-664-7600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2021-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA87606207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine