Provider Demographics
NPI:1700951142
Name:FORD, MARY JO (MD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:JO
Last Name:FORD
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 1:555 PIER AVENUE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:HERMOSA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90254-3800
Mailing Address - Country:US
Mailing Address - Phone:310-374-4100
Mailing Address - Fax:310-374-4111
Practice Address - Street 1:555 PIER AVENUE
Practice Address - Street 2:SUITE 1
Practice Address - City:HERMOSA BEACH
Practice Address - State:CA
Practice Address - Zip Code:90254-3800
Practice Address - Country:US
Practice Address - Phone:310-374-4100
Practice Address - Fax:310-374-4111
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2007-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG73858174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G738580Medicaid
CAE95002Medicare UPIN
CAWG73858MMedicare UPIN