Healthcare Provider Details

I. General information

NPI: 1104007657
Provider Name (Legal Business Name): CARLA BETH MARIENFELD MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/26/2007
Last Update Date: 10/28/2022
Certification Date: 10/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8950 VILLA LA JOLLA DR STE C101
LA JOLLA CA
92037-1727
US

IV. Provider business mailing address

9500 GILMAN DR MAIL CODE 0957
LA JOLLA CA
92093-0957
US

V. Phone/Fax

Practice location:
  • Phone: 858-249-1680
  • Fax: 858-249-1681
Mailing address:
  • Phone: 858-534-8730
  • Fax: 858-534-8863

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number047856
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License NumberA142922
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number047856
License Number StateCT
# 4
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberA142922
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License Number047856
License Number StateCT
# 6
Primary TaxonomyY
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License NumberA142922
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: