Provider Demographics
NPI:1629234091
Name:MA, MARY (O,D)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:
Last Name:MA
Suffix:
Gender:F
Credentials:O,D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:888 S. DISNEYLAND DRIVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92802-1828
Mailing Address - Country:US
Mailing Address - Phone:714-901-2007
Mailing Address - Fax:
Practice Address - Street 1:7677 CENTER AVE
Practice Address - Street 2:SUITE 301
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92647-3074
Practice Address - Country:US
Practice Address - Phone:714-901-2007
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-05
Last Update Date:2021-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13579152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAEU333XMedicare PIN