Provider Demographics
NPI:1679724462
Name:SARDO, MARIALYN JO (MD)
Entity Type:Individual
Prefix:MS
First Name:MARIALYN
Middle Name:JO
Last Name:SARDO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:9850 GENESEE AVE.
Mailing Address - Street 2:STE 410
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037
Mailing Address - Country:US
Mailing Address - Phone:858-452-6226
Mailing Address - Fax:858-452-6235
Practice Address - Street 1:9850 GENESEE AVENUE
Practice Address - Street 2:STE. 380
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037
Practice Address - Country:US
Practice Address - Phone:858-452-6226
Practice Address - Fax:858-452-6235
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-10
Last Update Date:2011-09-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG510662086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWG510660Medicaid
CAA93034Medicare UPIN
CA1613718Medicare PIN