Provider Demographics
NPI:1932489408
Name:O'CALLAGHAN, MARY ANNE (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ANNE
Last Name:O'CALLAGHAN
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 1:845 MARYLAND ST
Mailing Address - Street 2:
Mailing Address - City:EL SEGUNDO
Mailing Address - State:CA
Mailing Address - Zip Code:90245-2546
Mailing Address - Country:US
Mailing Address - Phone:310-640-9604
Mailing Address - Fax:
Practice Address - Street 1:845 MARYLAND ST
Practice Address - Street 2:
Practice Address - City:EL SEGUNDO
Practice Address - State:CA
Practice Address - Zip Code:90245-2546
Practice Address - Country:US
Practice Address - Phone:310-640-9604
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-27
Last Update Date:2011-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAFE19605207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine