Provider Demographics
NPI:1790704799
Name:MONROE, PHYLLIS R (MD)
Entity Type:Individual
Prefix:DR
First Name:PHYLLIS
Middle Name:R
Last Name:MONROE
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 1:1360 W 6TH ST
Mailing Address - Street 2:SUITE 315N
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90732-3514
Mailing Address - Country:US
Mailing Address - Phone:310-832-4517
Mailing Address - Fax:310-832-6419
Practice Address - Street 1:1360 W 6TH ST
Practice Address - Street 2:SUITE 315N
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90732-3514
Practice Address - Country:US
Practice Address - Phone:310-832-4517
Practice Address - Fax:310-832-6419
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG31583207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G31583Medicaid
CA00G31583Medicaid
CAG31583Medicare ID - Type Unspecified