Healthcare Provider Details

I. General information

NPI: 1699886564
Provider Name (Legal Business Name): AGATA MARRIOTT M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 08/28/2020
Certification Date: 08/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1349 CAMINO DEL MAR SUITE D
DEL MAR CA
92014-2553
US

IV. Provider business mailing address

1349 CAMINO DEL MAR SUITE D
DEL MAR CA
92014-2553
US

V. Phone/Fax

Practice location:
  • Phone: 858-755-0707
  • Fax: 858-755-0123
Mailing address:
  • Phone: 858-755-0707
  • Fax: 858-755-0123

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberA50325
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: