Provider Demographics
NPI:1205934593
Name:GIMNESS, MARY (DO)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:GIMNESS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 SEABROOK DR
Mailing Address - Street 2:
Mailing Address - City:DANA POINT
Mailing Address - State:CA
Mailing Address - Zip Code:92629-3216
Mailing Address - Country:US
Mailing Address - Phone:949-218-3121
Mailing Address - Fax:949-218-3121
Practice Address - Street 1:1801 W. ROMNEYA DR. ST 303
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92801
Practice Address - Country:US
Practice Address - Phone:714-808-5400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A8635207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX86350Medicaid
CAW20A8635AMedicare ID - Type Unspecified
CA00AX86350Medicaid