Healthcare Provider Details

I. General information

NPI: 1437311974
Provider Name (Legal Business Name): JASON JAMES MARENGO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2008
Last Update Date: 01/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 NUT TREE RD SUITE 390
VACAVILLE CA
95687-4100
US

IV. Provider business mailing address

1020 NUT TREE RD SUITE 390
VACAVILLE CA
95687-4100
US

V. Phone/Fax

Practice location:
  • Phone: 707-624-8000
  • Fax: 707-624-8001
Mailing address:
  • Phone: 707-624-8000
  • Fax: 707-624-8001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberA82346
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: