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General NPI Number Information
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NPI Number | 1104128941
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Entity Type | Organization
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Legal Business Name | LARRY MARIANELLA, MD A PROFESSIONAL CORP.
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Dates
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Enumeration Date | 11/30/2010
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Last Update Date | 11/30/2010
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Provider Practice Location Address
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Address Line | 1515 MONTGOMERY DR
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City | SANTA ROSA
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State | CA
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Zip | 95405-4500
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Country | US
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Telephone | 707-526-4865
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Fax | 707-526-5375
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Provider Business Mailing Address
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Address Line | 1515 MONTGOMERY DR
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City | SANTA ROSA
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State | CA
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Zip | 95405-4500
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Country | US
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Telephone | 707-526-4865
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Fax | 707-526-5375
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. LARRY MARIANELLA
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Credential | M.D.
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Telephone | 707-526-4865
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | G38835
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License Number State | CA
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