Provider Demographics
NPI:1952309288
Name:PERSKY, KATHLEEN MARIE (MD)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:MARIE
Last Name:PERSKY
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:PO BOX 2739
Mailing Address - Street 2:
Mailing Address - City:UKIAH
Mailing Address - State:CA
Mailing Address - Zip Code:95482-2739
Mailing Address - Country:US
Mailing Address - Phone:707-463-8000
Mailing Address - Fax:707-462-1111
Practice Address - Street 1:246 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:UKIAH
Practice Address - State:CA
Practice Address - Zip Code:95482-4533
Practice Address - Country:US
Practice Address - Phone:707-463-8011
Practice Address - Fax:707-463-8044
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-11
Last Update Date:2011-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00G566600208600000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G566600Medicaid
E54090Medicare UPIN
00G566600Medicare ID - Type Unspecified