MEDICARE: MARLON DEAN BLACK M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085R0202X	Diagnostic Radiology Physician	A84822	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	00A848220	OTHER	CA	BS

General Provider Information

NPI Number	:	1245442714
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARLON DEAN BLACK M.D.

Provider Business Mailing Address
First Line	:	DEPT LA 21613
Second Line	:
City	:	PASADENA
State	:	CA
Zip	:	91185-1613
Country	:	US
Telephone Number	:	949-263-8620
Fax Number	:	949-263-1639

Provider Business Practice Location Address
First Line	:	2320 BATH STREET SUITE 208
Second Line	:
City	:	SANTA BARBARA
State	:	CA
Zip	:	93105-5322
Country	:	US
Telephone Number	:	805-682-7984
Fax Number	:	805-569-2964

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/04/2007
Last Update Date	:	07/07/2022

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Directions to “ MARLON DEAN BLACK M.D.” Practice Location

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