Provider Demographics
NPI:1134192388
Name:SANFELIPPO, MARY LU (MD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:LU
Last Name:SANFELIPPO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15708 POMERADO RD
Mailing Address - Street 2:#N205
Mailing Address - City:POWAY
Mailing Address - State:CA
Mailing Address - Zip Code:92064-2066
Mailing Address - Country:US
Mailing Address - Phone:858-487-5732
Mailing Address - Fax:858-487-7173
Practice Address - Street 1:15708 POMERADO RD
Practice Address - Street 2:#N205
Practice Address - City:POWAY
Practice Address - State:CA
Practice Address - Zip Code:92064-2066
Practice Address - Country:US
Practice Address - Phone:858-487-5732
Practice Address - Fax:858-487-7173
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-08
Last Update Date:2012-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG021251174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA330132847OtherTIN
CAA41219Medicare UPIN