Provider Demographics
NPI:1508844796
Name:ALLEN, GEORGIA CAROL (DO)
Entity Type:Individual
Prefix:
First Name:GEORGIA
Middle Name:CAROL
Last Name:ALLEN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1310 CLUB DR
Mailing Address - Street 2:
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94592-1187
Mailing Address - Country:US
Mailing Address - Phone:707-638-5232
Mailing Address - Fax:707-638-5255
Practice Address - Street 1:365 TUOLUMNE ST
Practice Address - Street 2:
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94590-5700
Practice Address - Country:US
Practice Address - Phone:707-553-5509
Practice Address - Fax:707-553-5658
Is Sole Proprietor?:No
Enumeration Date:2006-01-06
Last Update Date:2015-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK7497207R00000X
CA20A6109207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8DB606OtherBCBS
TX045035506Medicaid
TXTXB142490Medicare PIN
TXF70480Medicare UPIN
8B7547Medicare Oscar/Certification