Healthcare Provider Details

I. General information

NPI: 1053762138
Provider Name (Legal Business Name): MARCOS FLEIDERMAN MD CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/29/2016
Last Update Date: 06/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18372 CLARK ST SUITE 212
TARZANA CA
91356-3508
US

IV. Provider business mailing address

PO BOX 2151
MALIBU CA
90265-7151
US

V. Phone/Fax

Practice location:
  • Phone: 818-708-9942
  • Fax:
Mailing address:
  • Phone: 818-986-9099
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number StateCA

VIII. Authorized Official

Name: MARCOS FLEIDERMAN
Title or Position: OWNER
Credential: M.D.
Phone: 818-986-9099