Provider Demographics
NPI:1295073468
Name:UNANUE, MARY L (MD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:L
Last Name:UNANUE
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 1:5 BEVERLY RIDGE TER
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90210-1343
Mailing Address - Country:US
Mailing Address - Phone:818-259-5099
Mailing Address - Fax:
Practice Address - Street 1:5 BEVERLY RIDGE TER
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90210-1343
Practice Address - Country:US
Practice Address - Phone:818-259-5099
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-23
Last Update Date:2013-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG87924207R00000X
FLME54554207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine