Healthcare Provider Details

I. General information

NPI: 1689695082
Provider Name (Legal Business Name): MARIENELLE BANEZ M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 04/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4300 ROSE DR
YORBA LINDA CA
92886-2026
US

IV. Provider business mailing address

279 IMPERIAL HWY SUITE 730
FULLERTON CA
92835-1041
US

V. Phone/Fax

Practice location:
  • Phone: 714-528-4211
  • Fax: 714-579-6868
Mailing address:
  • Phone: 714-449-4841
  • Fax: 714-449-4956

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA62285
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: