Provider Demographics
NPI:1588972806
Name:ST MARY SPECIALTY CLINIC
Entity type:Organization
Organization Name:ST MARY SPECIALTY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MOSES
Authorized Official - Middle Name:T
Authorized Official - Last Name:MUKAI
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:714-449-4800
Mailing Address - Street 1:DEPT LA 21190
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91185-1190
Mailing Address - Country:US
Mailing Address - Phone:714-449-4800
Mailing Address - Fax:714-449-4956
Practice Address - Street 1:19333 BEAR VALLEY RD STE 106
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92308-5149
Practice Address - Country:US
Practice Address - Phone:760-240-5505
Practice Address - Fax:760-240-5525
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-21
Last Update Date:2013-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty