Provider Demographics
NPI:1891752614
Name:TREPHAN, MARY ANN H (MD)
Entity Type:Individual
Prefix:
First Name:MARY ANN
Middle Name:H
Last Name:TREPHAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARY ANN
Other - Middle Name:
Other - Last Name:HANES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 4675
Mailing Address - Street 2:
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91359-1675
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18300 ROSCOE BLVD
Practice Address - Street 2:
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91328
Practice Address - Country:US
Practice Address - Phone:818-885-8500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-26
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG85040207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G850400Medicaid
CAAP861ZMedicare PIN
CAHG85040Medicare PIN
CA00G850400Medicaid