Provider Demographics
NPI:1104007657
Name:MARIENFELD, CARLA BETH (MD)
Entity Type:Individual
Prefix:DR
First Name:CARLA
Middle Name:BETH
Last Name:MARIENFELD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9500 GILMAN DR
Mailing Address - Street 2:MAIL CODE 0957
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92093-0957
Mailing Address - Country:US
Mailing Address - Phone:858-534-8730
Mailing Address - Fax:858-534-8863
Practice Address - Street 1:8950 VILLA LA JOLLA DR STE C101
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-1727
Practice Address - Country:US
Practice Address - Phone:858-249-1680
Practice Address - Fax:858-249-1681
Is Sole Proprietor?:No
Enumeration Date:2007-11-26
Last Update Date:2022-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0478562084A0401X, 2084P0800X, 2084P0802X
CAA1429222084A0401X, 2084P0800X, 2084P0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Psychiatry
No2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Medicine
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTD400073259OtherMEDICARE PROVIDER/SUPPLIER NUMBER
CT008003745Medicaid
CT008022626Medicaid
CT008022622Medicaid
CTD400073259OtherMEDICARE PROVIDER/SUPPLIER NUMBER
CT004082286Medicaid
CT008039745Medicaid
CT004082260Medicaid
CT008003745Medicaid
CTC01033OtherMEDICARE PTAN
CT04217099Medicaid
CT500000315Medicaid