Provider Demographics
NPI:1497765614
Name:DU QUETTE, MARY WALCH (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:WALCH
Last Name:DU QUETTE
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 1:2020 GENESEE AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-4219
Mailing Address - Country:US
Mailing Address - Phone:858-616-8100
Mailing Address - Fax:858-569-5209
Practice Address - Street 1:2020 GENESEE AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-4219
Practice Address - Country:US
Practice Address - Phone:858-616-8100
Practice Address - Fax:858-569-5209
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2013-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG70844208100000X, 2081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G708440Medicaid
CA00G708440Medicaid
CAF54473Medicare UPIN