Basic Information
| Provider Information | |||||||||
| NPI: | 1295746618 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARRIEDO-CENICEROS | ||||||||
| FirstName: | MARIA | ||||||||
| MiddleName: | TERESA | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4004 BEYER BLVD | ||||||||
| Address2: | |||||||||
| City: | SAN YSIDRO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921732007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6194284463 | ||||||||
| FaxNumber: | 6194282625 | ||||||||
| Practice Location | |||||||||
| Address1: | 1136 D AVENUE | ||||||||
| Address2: | |||||||||
| City: | NATIONAL CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 91950 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6193362300 | ||||||||
| FaxNumber: | 6193362323 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 207Q00000X | A78373 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | FHC70267F | 01 | MEDI-CAL | OTHER |