Basic Information
| Provider Information | |||||||||
| NPI: | 1710295423 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CORDOVA - GONZALEZ | ||||||||
| FirstName: | MARIA | ||||||||
| MiddleName: | I | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 289 GREAT RD STE G1 | ||||||||
| Address2: | |||||||||
| City: | ACTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 017204766 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9786791200 | ||||||||
| FaxNumber: | 9784864037 | ||||||||
| Practice Location | |||||||||
| Address1: | 209 E 7TH ST | ||||||||
| Address2: | |||||||||
| City: | MADERA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 936383780 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5596733508 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2010 | ||||||||
| LastUpdateDate: | 03/29/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | A166630 | CA | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0800X | 266938 | MA | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0800X | 20819 | PR | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 020819 | 01 | PR | STATE LICENSE | OTHER | 266938 | 01 | MA | STATE LICENSE | OTHER | S4120 | 01 | TX | STATE LICENSE | OTHER | 2021-00445 | 01 | NC | STATE LICENSE | OTHER | ME143381 | 01 | FL | STATE LICENSE | OTHER | A166630 | 01 | CA | STATE LICENSE | OTHER |