Healthcare Provider Details

I. General information

NPI: 1427085661
Provider Name (Legal Business Name): MARK LYMAN MAGULAC MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2006
Last Update Date: 10/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11440 W BERNARDO CT SUITE 300
SAN DIEGO CA
92127-1641
US

IV. Provider business mailing address

PO BOX 511267
LOS ANGELES CA
90051-7822
US

V. Phone/Fax

Practice location:
  • Phone: 858-487-3330
  • Fax: 858-487-3331
Mailing address:
  • Phone: 866-284-2771
  • Fax: 800-334-1041

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberG56157
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberG56157
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: