Provider Demographics
NPI:1376689638
Name:KESTERSON, MARY LAURA
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:LAURA
Last Name:KESTERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:531 S CENTRAL PARK AVE E
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92802-1471
Mailing Address - Country:US
Mailing Address - Phone:714-635-2011
Mailing Address - Fax:714-535-7010
Practice Address - Street 1:531 S CENTRAL PARK AVE E
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92802-1471
Practice Address - Country:US
Practice Address - Phone:714-635-2011
Practice Address - Fax:714-535-7010
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2008-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1074740001Medicare NSC