Healthcare Provider Details

I. General information

NPI: 1306367958
Provider Name (Legal Business Name): MARLON MINERA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2017
Last Update Date: 06/09/2022
Certification Date: 06/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10800 MAGNOLIA AVE # 3
RIVERSIDE CA
92505-3043
US

IV. Provider business mailing address

10800 MAGNOLIA AVE # 3
RIVERSIDE CA
92505-3043
US

V. Phone/Fax

Practice location:
  • Phone: 951-602-4230
  • Fax:
Mailing address:
  • Phone: 951-602-4230
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License NumberA169462
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: