Provider Demographics
NPI:1487627816
Name:MALABED-VERONA, GLORIA JEAN
Entity Type:Individual
Prefix:
First Name:GLORIA JEAN
Middle Name:
Last Name:MALABED-VERONA
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 1:2121 LEGENDS CT
Mailing Address - Street 2:
Mailing Address - City:MERCED
Mailing Address - State:CA
Mailing Address - Zip Code:95340-0740
Mailing Address - Country:US
Mailing Address - Phone:209-384-4400
Mailing Address - Fax:209-384-4126
Practice Address - Street 1:900 W OLIVE AVE STE B
Practice Address - Street 2:
Practice Address - City:MERCED
Practice Address - State:CA
Practice Address - Zip Code:95348-2401
Practice Address - Country:US
Practice Address - Phone:209-384-4400
Practice Address - Fax:209-384-4126
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-08
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA67510207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A675100Medicare ID - Type UnspecifiedPROVIDER