Healthcare Provider Details

I. General information

NPI: 1053766196
Provider Name (Legal Business Name): MARIELLE CELIS BOLANO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2016
Last Update Date: 05/21/2026
Certification Date: 05/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8000 MARINA BLVD FL 8
BRISBANE CA
94005-1844
US

IV. Provider business mailing address

FILE 57326
LOS ANGELES CA
90074-7326
US

V. Phone/Fax

Practice location:
  • Phone: 415-514-3577
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License NumberA166900
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: