Healthcare Provider Details

I. General information

NPI: 1245292085
Provider Name (Legal Business Name): MARCELLE MAHAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2006
Last Update Date: 03/29/2021
Certification Date: 03/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2700 DOLBEER ST
EUREKA CA
95501-4736
US

IV. Provider business mailing address

PO BOX 2717
MCKINLEYVILLE CA
95519-2717
US

V. Phone/Fax

Practice location:
  • Phone: 707-269-4250
  • Fax:
Mailing address:
  • Phone: 707-499-8781
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberG71860
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberG078160
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: