Provider Demographics
NPI:1427078039
Name:TERRITO, MARY CAROL (MD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:CAROL
Last Name:TERRITO
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 1:5767 W CENTURY BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-5632
Mailing Address - Country:US
Mailing Address - Phone:310-206-6909
Mailing Address - Fax:
Practice Address - Street 1:200 MEDICAL PLAZA
Practice Address - Street 2:#365,530,420,120
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-3075
Practice Address - Country:US
Practice Address - Phone:310-206-6909
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2010-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC34130207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C341300Medicaid
CAA35510Medicare UPIN
CAWC34130AMedicare PIN