Healthcare Provider Details

I. General information

NPI: 1023157021
Provider Name (Legal Business Name): MARA RENEE ARCHAMBAULT MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARA RENEE SIEVERS MD

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 12/04/2025
Certification Date: 12/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3833 EMERALD AVE
LA VERNE CA
91750-2904
US

IV. Provider business mailing address

PO BOX 35380
LAS VEGAS NV
89133-5380
US

V. Phone/Fax

Practice location:
  • Phone: 909-593-4531
  • Fax: 909-392-9598
Mailing address:
  • Phone: 702-579-3203
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD2008-0205
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: