Provider Demographics
NPI:1861576480
Name:ROMO, MARY SHIRLEY (MD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:SHIRLEY
Last Name:ROMO
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:PO BOX 2279
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90255-1579
Mailing Address - Country:US
Mailing Address - Phone:323-562-6930
Mailing Address - Fax:323-562-6798
Practice Address - Street 1:5101 FLORENCE AVE
Practice Address - Street 2:SUITE 5
Practice Address - City:BELL
Practice Address - State:CA
Practice Address - Zip Code:90201-3801
Practice Address - Country:US
Practice Address - Phone:323-562-6930
Practice Address - Fax:323-562-6798
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2015-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG64064174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G640640Medicaid
CA00G640640Medicaid
CAG64064Medicare ID - Type Unspecified