Healthcare Provider Details

I. General information

NPI: 1083639090
Provider Name (Legal Business Name): DR. DAVID E MARCUS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1128 SONOMA AVE
SANTA ROSA CA
95405-4806
US

IV. Provider business mailing address

2491 INCLINE DR
SANTA ROSA CA
95404-1835
US

V. Phone/Fax

Practice location:
  • Phone: 707-575-1626
  • Fax: 707-575-3941
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberG054206
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: