1245442714 NPI number — MARLON DEAN BLACK M.D.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245442714 NPI number — MARLON DEAN BLACK M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLACK
Provider First Name:
MARLON
Provider Middle Name:
DEAN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
BLACK
Provider Other First Name:
M.
Provider Other Middle Name:
DEAN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1245442714
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/07/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
DEPT LA 21613
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PASADENA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91185-1613
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
949-263-8620
Provider Business Mailing Address Fax Number:
949-263-1639

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2320 BATH STREET SUITE 208
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SANTA BARBARA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93105-5322
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-682-7984
Provider Business Practice Location Address Fax Number:
805-569-2964
Provider Enumeration Date:
05/04/2007

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: 2085R0202X , with the licence number:  A84822 , 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: 00A848220 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00A848220 . This is a "BS" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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