Provider Demographics
NPI:1376515924
Name:MARA, MARIA LOURDES DE LOS SANTOS (MD)
Entity Type:Individual
Prefix:DR
First Name:MARIA LOURDES
Middle Name:DE LOS SANTOS
Last Name:MARA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:2939 ALTA VIEW DR
Mailing Address - Street 2:SUITE J
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92139-3394
Mailing Address - Country:US
Mailing Address - Phone:619-475-5411
Mailing Address - Fax:619-475-1839
Practice Address - Street 1:2939 ALTA VIEW DR
Practice Address - Street 2:SUITE J
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92139-3394
Practice Address - Country:US
Practice Address - Phone:619-475-5411
Practice Address - Fax:619-475-1839
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-07
Last Update Date:2017-04-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA51864207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A518642Medicaid
CA00A518642Medicaid
CA271258181Medicare PIN
CAF96657Medicare UPIN