Basic Information
| Provider Information | |||||||||
| NPI: | 1831328616 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | UDOWENKO | ||||||||
| FirstName: | MARINA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D. O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | UDOWENKO | ||||||||
| OtherFirstName: | MARINA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | D.O. | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3955 BONITA RD | ||||||||
| Address2: | |||||||||
| City: | BONITA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 919021230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6196911990 | ||||||||
| FaxNumber: | 6196915977 | ||||||||
| Practice Location | |||||||||
| Address1: | 450 FOURTH AVE STE 408 | ||||||||
| Address2: | |||||||||
| City: | CHULA VISTA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 919104430 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6196911990 | ||||||||
| FaxNumber: | 6196915977 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2009 | ||||||||
| LastUpdateDate: | 12/10/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | BP10034298 | TX | N | Allopathic & Osteopathic Physicians | Family Medicine | 207QS0010X | P7996 | TX | N | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine | 207Q00000X | 20A14136 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.