Healthcare Provider Details

I. General information

NPI: 1548419518
Provider Name (Legal Business Name): MARIE MBOUNI M.D A MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2008
Last Update Date: 12/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3751 KATELLA AVE
LOS ALAMITOS CA
90720-3101
US

IV. Provider business mailing address

101 S 1ST ST SUITE #1000
BURBANK CA
91502-1938
US

V. Phone/Fax

Practice location:
  • Phone: 562-799-3160
  • Fax: 562-799-3133
Mailing address:
  • Phone: 818-845-6206
  • Fax: 818-845-9774

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberC52701
License Number StateCA

VIII. Authorized Official

Name: DR. MARIE T. MBOUNI-ESSOMBA
Title or Position: PRESIDENT
Credential: M.D
Phone: 218-233-3421