MEDICARE: DR. MARIAN J WYMORE 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	207Q00000X	Family Medicine Physician	G50846	CA

General Provider Information

NPI Number	:	1902184062
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARIAN J WYMORE M.D.

Provider Business Mailing Address
First Line	:	27336 SUNNYRIDGE RD
Second Line	:
City	:	PALOS VERDES PENINSULA
State	:	CA
Zip	:	90274-4037
Country	:	US
Telephone Number	:	310-780-0155
Fax Number	:	310-377-8874

Provider Business Practice Location Address
First Line	:	27336 SUNNYRIDGE RD
Second Line	:
City	:	PALOS VERDES PENINSULA
State	:	CA
Zip	:	90274-4037
Country	:	US
Telephone Number	:	310-780-0155
Fax Number	:	310-377-8874

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

Provider Enumeration Date	:	07/23/2011
Last Update Date	:	07/23/2011

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