Provider Demographics
NPI:1871598706
Name:GENEVIEVE, MARY S (MD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:S
Last Name:GENEVIEVE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:MARY
Other - Middle Name:S
Other - Last Name:AMIR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 976
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93302-0976
Mailing Address - Country:US
Mailing Address - Phone:805-544-7511
Mailing Address - Fax:
Practice Address - Street 1:1035 PEACH ST
Practice Address - Street 2:STE 204
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-2700
Practice Address - Country:US
Practice Address - Phone:805-544-7511
Practice Address - Fax:805-544-7650
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-16
Last Update Date:2020-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG849372084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG61237Medicare UPIN
CAW15124Medicare PIN
CA00G849370Medicaid