1275585622 NPI number — PANOS Z MARMARELIS PH.D., M.D.

Table of content: PANOS Z MARMARELIS PH.D., M.D. (NPI 1275585622)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275585622 NPI number — PANOS Z MARMARELIS PH.D., M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARMARELIS
Provider First Name:
PANOS
Provider Middle Name:
Z
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PH.D., M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1275585622
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/22/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1045 ATLANTIC AVE
Provider Second Line Business Mailing Address:
719
Provider Business Mailing Address City Name:
LONG BEACH
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90813-3412
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
562-591-1324
Provider Business Mailing Address Fax Number:
562-437-1054

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1045 ATLANTIC AVE
Provider Second Line Business Practice Location Address:
719
Provider Business Practice Location Address City Name:
LONG BEACH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90813-3412
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
562-591-1324
Provider Business Practice Location Address Fax Number:
562-437-1054
Provider Enumeration Date:
05/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2084N0400X , with the licence number:  G37550 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00G375500 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: WG37550D . This is a "PTAN PROVIDER IDENTIFIER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 130005307 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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