Healthcare Provider Details

I. General information

NPI: 1659759074
Provider Name (Legal Business Name): MARIETTA JOY LUZON-VIDAD NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2015
Last Update Date: 08/21/2026
Certification Date: 08/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20920 CHICO ST
CARSON CA
90746-3603
US

IV. Provider business mailing address

3604 W ESTATES LN UNIT 202
ROLLING HILLS ESTATES CA
90274-4171
US

V. Phone/Fax

Practice location:
  • Phone: 424-444-5097
  • Fax: 833-973-3630
Mailing address:
  • Phone: 310-354-4311
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95001455
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: