Provider Demographics
NPI:1689778607
Name:MARYLOU ROMO-GRITZEWSKY
Entity Type:Organization
Organization Name:MARYLOU ROMO-GRITZEWSKY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:MARYLOU
Authorized Official - Middle Name:
Authorized Official - Last Name:ROMO-GRITZEWSKY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:831-728-0440
Mailing Address - Street 1:268 GREEN VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:FREEDOM
Mailing Address - State:CA
Mailing Address - Zip Code:95019-3139
Mailing Address - Country:US
Mailing Address - Phone:831-728-0440
Mailing Address - Fax:831-728-4293
Practice Address - Street 1:268 GREEN VALLEY RD
Practice Address - Street 2:
Practice Address - City:FREEDOM
Practice Address - State:CA
Practice Address - Zip Code:95019-3139
Practice Address - Country:US
Practice Address - Phone:831-728-0440
Practice Address - Fax:831-728-4293
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA76531207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1790795730OtherNPI DR. ROMO
CA=========OtherTAX ID