Provider Demographics
NPI:1790795730
Name:ROMO-GRITZEWSKY, MARYLOU (MD)
Entity Type:Individual
Prefix:
First Name:MARYLOU
Middle Name:
Last Name:ROMO-GRITZEWSKY
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 1:268 GREEN VALLEY RD BLDG 4
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:
Practice Address - Street 1:268 GREEN VALLEY RD
Practice Address - Street 2:BLDG 4
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
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA76531208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A765310Medicaid
CAH59236Medicare UPIN
CA00A765310Medicaid