Provider Demographics
NPI:1558561563
Name:LINDAE, MARY LOUISE (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:LOUISE
Last Name:LINDAE
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 1:6335 N FRESNO STREET
Mailing Address - Street 2:#206
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93710
Mailing Address - Country:US
Mailing Address - Phone:559-432-8852
Mailing Address - Fax:559-432-8895
Practice Address - Street 1:6335 N FRESNO STREET
Practice Address - Street 2:#206
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93710
Practice Address - Country:US
Practice Address - Phone:559-432-8852
Practice Address - Fax:559-432-8895
Is Sole Proprietor?:No
Enumeration Date:2007-07-19
Last Update Date:2012-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00G533740207N00000X, 207ND0900X, 207NP0225X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
No207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric Dermatology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA070004431OtherMEDICARE RAILROAD
CAE75073Medicare UPIN
CA00G533740Medicare PIN