Healthcare Provider Details

I. General information

NPI: 1568734655
Provider Name (Legal Business Name): BERTRAND A. MARCANO, MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/03/2012
Last Update Date: 02/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 E CESAR E CHAVEZ AVE SUITE 3450
LOS ANGELES CA
90033-2424
US

IV. Provider business mailing address

1700 CESAR E CHAVEZ AVE SUITE 3450
LOS ANGELES CA
90033
US

V. Phone/Fax

Practice location:
  • Phone: 323-261-0259
  • Fax: 323-261-0073
Mailing address:
  • Phone: 323-261-0259
  • Fax: 323-261-0073

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code282NC2000X
TaxonomyChildren's Hospital
License NumberA22276
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License NumberA22276
License Number StateCA

VIII. Authorized Official

Name: MR. BERTRAND A MARCANO
Title or Position: OWNER
Credential: M.D
Phone: 323-261-0259