Healthcare Provider Details

I. General information

NPI: 1871297291
Provider Name (Legal Business Name): PAUL DAVID MARCUS PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2023
Last Update Date: 03/29/2023
Certification Date: 03/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2975 SACRAMENTO ST
BERKELEY CA
94702-2534
US

IV. Provider business mailing address

2975 SACRAMENTO ST
BERKELEY CA
94702-2534
US

V. Phone/Fax

Practice location:
  • Phone: 510-644-0200
  • Fax: 510-644-2044
Mailing address:
  • Phone: 510-644-0200
  • Fax: 510-644-2044

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number11823
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: