Healthcare Provider Details

I. General information

NPI: 1225186190
Provider Name (Legal Business Name): WAYMAN D. MERRILL III MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 12/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 N SEPULVEDA BLVD STE 210
MANHATTAN BEACH CA
90266-6849
US

IV. Provider business mailing address

4335 MARINA CITY DR UNIT 1144
MARINA DEL REY CA
90292-5802
US

V. Phone/Fax

Practice location:
  • Phone: 310-379-2134
  • Fax:
Mailing address:
  • Phone: 310-291-4243
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberG29834
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: