Basic Information
| Provider Information | |||||||||
| NPI: | 1073685814 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FORY | ||||||||
| FirstName: | LINDA | ||||||||
| MiddleName: | WASHINGTON | ||||||||
| NamePrefix: | |||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WASHINGTON | ||||||||
| OtherFirstName: | LINDA | ||||||||
| OtherMiddleName: | KAREN | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2050 S BLOSSER RD | ||||||||
| Address2: | |||||||||
| City: | SANTA MARIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934587310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8053618028 | ||||||||
| FaxNumber: | 8053618097 | ||||||||
| Practice Location | |||||||||
| Address1: | 425 W CENTRAL AVE STE 201 | ||||||||
| Address2: | |||||||||
| City: | LOMPOC | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934362807 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3720805737 | ||||||||
| FaxNumber: | 8057371772 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2006 | ||||||||
| LastUpdateDate: | 10/17/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | MD60481573 | WA | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | A73101 | CA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 00A731010 | 05 | CA | MEDICAID |