Basic Information
| Provider Information | |||||||||
| NPI: | 1356305866 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MAA | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5 BON AIR ROAD #101 | ||||||||
| Address2: | |||||||||
| City: | LARKSPUR | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4159242515 | ||||||||
| FaxNumber: | 4159242661 | ||||||||
| Practice Location | |||||||||
| Address1: | 250 BON AIR RD | ||||||||
| Address2: | |||||||||
| City: | GREENBRAE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 949041702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4159242515 | ||||||||
| FaxNumber: | 4159242661 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2006 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | A55909 | CA | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 0A5590900 | 05 | CA | MEDICAID |