Provider Demographics
NPI:1316007156
Name:ANESON-MACLEON, SOPHIE (MD)
Entity Type:Individual
Prefix:
First Name:SOPHIE
Middle Name:
Last Name:ANESON-MACLEON
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 1:1360 N MCDOWELL BLVD
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94954-1115
Mailing Address - Country:US
Mailing Address - Phone:707-565-4708
Mailing Address - Fax:
Practice Address - Street 1:1360 N MCDOWELL BLVD
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94954-1115
Practice Address - Country:US
Practice Address - Phone:707-565-4708
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2014-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG490652084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF39743Medicare UPIN
CA00G490650Medicare ID - Type Unspecified