Provider Demographics
NPI:1104835487
Name:MERRIMAN, MARK E (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:E
Last Name:MERRIMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:3116 W MARCH LN
Mailing Address - Street 2:STE. 200
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95219-2369
Mailing Address - Country:US
Mailing Address - Phone:209-473-6555
Mailing Address - Fax:209-473-6544
Practice Address - Street 1:227 W JANSS RD
Practice Address - Street 2:STE 240
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91360-1848
Practice Address - Country:US
Practice Address - Phone:805-371-0455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2010-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG71754207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G717541Medicaid
CA00G717541Medicaid
AW545ZMedicare PIN