Healthcare Provider Details

I. General information

NPI: 1770604779
Provider Name (Legal Business Name): MARSHAK MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 07/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3484 E 1ST ST
LOS ANGELES CA
90063-2946
US

IV. Provider business mailing address

PO BOX 63194
LOS ANGELES CA
90063-0194
US

V. Phone/Fax

Practice location:
  • Phone: 323-268-4436
  • Fax: 323-264-3049
Mailing address:
  • Phone: 323-268-4436
  • Fax: 323-264-3049

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0000X
TaxonomyAdolescent Medicine (Family Medicine) Physician
License NumberA29118
License Number StateCA

VIII. Authorized Official

Name: DR. HERBERT MARSHAK
Title or Position: M.D.
Credential: M.D.
Phone: 323-268-4436