Healthcare Provider Details

I. General information

NPI: 1972047397
Provider Name (Legal Business Name): MARIANNE HOM-TEDLA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/05/2016
Last Update Date: 01/30/2026
Certification Date: 01/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1441 EASTLAKE AVE
LOS ANGELES CA
90089-0177
US

IV. Provider business mailing address

PO BOX 50938
LOS ANGELES CA
90074-0938
US

V. Phone/Fax

Practice location:
  • Phone: 323-276-3705
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License NumberMD481850
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License NumberA146335
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: