Provider Demographics
NPI:1063436509
Name:MACIOG, PATRICIA ANN (MD)
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:ANN
Last Name:MACIOG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6226 E SPRING ST
Mailing Address - Street 2:SUITE 240
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90815-1423
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6226 E SPRING ST
Practice Address - Street 2:SUITE 240
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90815-1423
Practice Address - Country:US
Practice Address - Phone:562-938-7129
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2009-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA49415207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC93195Medicare UPIN