Provider Demographics
NPI:1982639993
Name:KASEM, MARY (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:KASEM
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 1:840 TOWNE CENTER DR
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-5900
Mailing Address - Country:US
Mailing Address - Phone:909-398-1500
Mailing Address - Fax:909-398-1488
Practice Address - Street 1:430 W BASELINE RD
Practice Address - Street 2:
Practice Address - City:CLAREMONT
Practice Address - State:CA
Practice Address - Zip Code:91711-1607
Practice Address - Country:US
Practice Address - Phone:909-621-3916
Practice Address - Fax:909-625-0903
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA72302207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH66765Medicare UPIN
CABU519YMedicare PIN
CABU519XMedicare PIN