Healthcare Provider Details

I. General information

NPI: 1275549636
Provider Name (Legal Business Name): MARISSA VASQUEZ MACHUCA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARISSA VASQUEZ MD

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 09/17/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4343 LANKERSHIM BLVD STE 200
NORTH HOLLYWOOD CA
91602-2705
US

IV. Provider business mailing address

5767 W CENTURY BLVD STE 400
LOS ANGELES CA
90045-5631
US

V. Phone/Fax

Practice location:
  • Phone: 818-843-9038
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberA89338
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA89338
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: