Provider Demographics
NPI:1831328616
Name:UDOWENKO, MARINA (D O)
Entity type:Individual
Prefix:DR
First Name:MARINA
Middle Name:
Last Name:UDOWENKO
Suffix:
Gender:F
Credentials:D O
Other - Prefix:DR
Other - First Name:MARINA
Other - Middle Name:
Other - Last Name:UDOWENKO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:3955 BONITA RD
Mailing Address - Street 2:
Mailing Address - City:BONITA
Mailing Address - State:CA
Mailing Address - Zip Code:91902-1230
Mailing Address - Country:US
Mailing Address - Phone:619-691-1990
Mailing Address - Fax:619-691-5977
Practice Address - Street 1:450 FOURTH AVE STE 408
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910-4430
Practice Address - Country:US
Practice Address - Phone:619-691-1990
Practice Address - Fax:619-691-5977
Is Sole Proprietor?:No
Enumeration Date:2009-07-14
Last Update Date:2021-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP10034298207Q00000X
TXP7996207QS0010X
CA20A14136207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine