MEDICARE: MARVIN H FIRESTONE 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	2084F0202X	Forensic Psychiatry Physician	G192950	CA
2	2084P0800X	Psychiatry Physician	G192950	CA
3	2084P0805X	Geriatric Psychiatry Physician	G192950	CA

General Provider Information

NPI Number	:	1376540245
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARVIN H FIRESTONE M.D.

Provider Business Mailing Address
First Line	:	1700 S EL CAMINO REAL
Second Line	:	SUITE 204
City	:	SAN MATEO
State	:	CA
Zip	:	94402-3047
Country	:	US
Telephone Number	:	650-212-4900
Fax Number	:

Provider Business Practice Location Address
First Line	:	520 S EL CAMINO REAL
Second Line	:	SUITE 310
City	:	SAN MATEO
State	:	CA
Zip	:	94402-1726
Country	:	US
Telephone Number	:	650-212-4900
Fax Number	:

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

Provider Enumeration Date	:	07/06/2005
Last Update Date	:	10/14/2013

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