Healthcare Provider Details

I. General information

NPI: 1396776746
Provider Name (Legal Business Name): JAIRO J MARIN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 03/07/2023
Certification Date: 06/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1140 W. LA VETA AVE. SUITE # 640
ORANGE CA
92868-4228
US

IV. Provider business mailing address

1140 W. LA VETA AVE. SUITE # 640
ORANGE CA
92868-4228
US

V. Phone/Fax

Practice location:
  • Phone: 714-564-3300
  • Fax: 714-564-3318
Mailing address:
  • Phone: 714-564-3300
  • Fax: 714-564-3318

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberG49117
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License NumberG49117
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: