Healthcare Provider Details

I. General information

NPI: 1194213678
Provider Name (Legal Business Name): DAVID EARL MARRIOTT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/30/2018
Last Update Date: 08/03/2022
Certification Date: 08/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

444 BRUCE ST
YREKA CA
96097-3450
US

IV. Provider business mailing address

902 NORTHVIEW CIR
YREKA CA
96097-2139
US

V. Phone/Fax

Practice location:
  • Phone: 530-842-4121
  • Fax:
Mailing address:
  • Phone: 360-632-6952
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101271644
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA180921
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number0101271644
License Number StateVA
# 5
Primary TaxonomyN
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License Number0101271644
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: