Provider Demographics
NPI:1841202983
Name:DARTEY, MAXWELL A (MD)
Entity Type:Individual
Prefix:
First Name:MAXWELL
Middle Name:A
Last Name:DARTEY
Suffix:
Gender:M
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 165
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90732-3514
Mailing Address - Country:US
Mailing Address - Phone:310-241-1350
Mailing Address - Fax:310-241-1357
Practice Address - Street 1:1360 W 6TH ST
Practice Address - Street 2:SUITE 165
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90732-3514
Practice Address - Country:US
Practice Address - Phone:310-241-1350
Practice Address - Fax:310-241-1357
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA33447207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A334470Medicaid
CAW19193Medicare ID - Type UnspecifiedMEDICARE GROUP #
CA00A334470Medicaid
CAA27156Medicare UPIN