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General NPI Number Information
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NPI Number | 1215071790
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Entity Type | Organization
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Legal Business Name | GUSTAVO MARKS
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Dates
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Enumeration Date | 02/16/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 22201 SHERMAN WAY
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City | CANOGA PARK
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State | CA
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Zip | 91303-1048
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Country | US
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Telephone | 818-999-5900
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 27206
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City | LOS ANGELES
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State | CA
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Zip | 90027-0206
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | GUSTAVO MARKS
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Credential | M.D.
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Telephone | 2138189995900
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | A54483
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License Number State | CA
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