Provider Demographics
NPI:1982656724
Name:CHRISTENSEN, MARY BRODERICK (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:BRODERICK
Last Name:CHRISTENSEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:ANGELA PEARL
Other - Last Name:BRODERICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1600 9TH ST
Mailing Address - Street 2:ROOM 205 MAILSTOP 23
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95814-6414
Mailing Address - Country:US
Mailing Address - Phone:916-654-2431
Mailing Address - Fax:916-654-2431
Practice Address - Street 1:15000 ARNOLD DR
Practice Address - Street 2:
Practice Address - City:ELDRIDGE
Practice Address - State:CA
Practice Address - Zip Code:95431-8900
Practice Address - Country:US
Practice Address - Phone:707-938-6690
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2011-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG72502207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
00G725021Medicare ID - Type Unspecified
F67890Medicare UPIN