Healthcare Provider Details

I. General information

NPI: 1699775692
Provider Name (Legal Business Name): MICHAEL MARINO D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2005
Last Update Date: 04/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

731 S HIGHLAND AVE
FULLERTON CA
92832-2753
US

IV. Provider business mailing address

731 S HIGHLAND AVE
FULLERTON CA
92832-2753
US

V. Phone/Fax

Practice location:
  • Phone: 714-446-5100
  • Fax: 714-449-0726
Mailing address:
  • Phone: 714-446-5100
  • Fax: 714-449-0726

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number20A6732
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: