Provider Demographics
NPI:1356363154
Name:MAIN, DENISE (MD)
Entity type:Individual
Prefix:
First Name:DENISE
Middle Name:
Last Name:MAIN
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 1:325 DISTEL CIR
Mailing Address - Street 2:
Mailing Address - City:LOS ALTOS
Mailing Address - State:CA
Mailing Address - Zip Code:94022-1408
Mailing Address - Country:US
Mailing Address - Phone:415-600-6400
Mailing Address - Fax:415-369-1384
Practice Address - Street 1:1100 VAN NESS AVE FL 4
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94109-6978
Practice Address - Country:US
Practice Address - Phone:415-600-6400
Practice Address - Fax:415-369-1384
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2021-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG60240207VM0101X, 207SG0201X
CA387929208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207SG0201XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Genetics (M.D.)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G602401Medicare ID - Type Unspecified
CAA53572Medicare UPIN