Basic Information
| Provider Information | |||||||||
| NPI: | 1508844796 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ALLEN | ||||||||
| FirstName: | GEORGIA | ||||||||
| MiddleName: | CAROL | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1310 CLUB DR | ||||||||
| Address2: | |||||||||
| City: | VALLEJO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945921187 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7076385232 | ||||||||
| FaxNumber: | 7076385255 | ||||||||
| Practice Location | |||||||||
| Address1: | 365 TUOLUMNE ST | ||||||||
| Address2: | |||||||||
| City: | VALLEJO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945905700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7075535509 | ||||||||
| FaxNumber: | 7075535658 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/06/2006 | ||||||||
| LastUpdateDate: | 06/18/2015 | ||||||||
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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 | 207R00000X | K7497 | TX | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 20A6109 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 8DB606 | 01 | TX | BCBS | OTHER | 045035506 | 05 | TX | MEDICAID |