Provider Demographics
NPI:1720575988
Name:ALTAMIRANO, MARYIN JUDITH (MD)
Entity Type:Individual
Prefix:
First Name:MARYIN
Middle Name:JUDITH
Last Name:ALTAMIRANO
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:FILE #54701
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90074-2804
Mailing Address - Country:US
Mailing Address - Phone:909-651-4300
Mailing Address - Fax:
Practice Address - Street 1:81 HIGHLAND SPRINGS AVE STE 301
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:CA
Practice Address - Zip Code:92223-3170
Practice Address - Country:US
Practice Address - Phone:951-846-2611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-13
Last Update Date:2021-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA166892207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine