Provider Demographics
NPI:1336240837
Name:PENA-PRIDMORE, MARY ROSALIE (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ROSALIE
Last Name:PENA-PRIDMORE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:ROSALIE
Other - Last Name:PENA-PRIDMORE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1114 YUBA ST RM 144
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95901-4838
Mailing Address - Country:US
Mailing Address - Phone:530-749-3242
Mailing Address - Fax:530-741-9274
Practice Address - Street 1:9980 LIVE OAK BLVD
Practice Address - Street 2:
Practice Address - City:LIVE OAK
Practice Address - State:CA
Practice Address - Zip Code:95953-2334
Practice Address - Country:US
Practice Address - Phone:530-749-3242
Practice Address - Fax:530-749-3248
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2018-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51623207Q00000X
CAC51623207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAEXE70043FMedicaid
CAEXE70043FMedicaid