Provider Demographics
NPI:1750352621
Name:MAHONEY, MARY ELLEN (MD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ELLEN
Last Name:MAHONEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 990208
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96099-0208
Mailing Address - Country:US
Mailing Address - Phone:530-212-0073
Mailing Address - Fax:844-440-2311
Practice Address - Street 1:636 HARRIS ST STE A
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95503-4448
Practice Address - Country:US
Practice Address - Phone:707-476-0690
Practice Address - Fax:707-476-0692
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-30
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG48569208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G485690Medicaid
CA00G485690Medicaid
CAA51100Medicare UPIN