Provider Demographics
NPI:1114945680
Name:MECUM, ROBERT A (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:A
Last Name:MECUM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1605 EUSTON RD
Mailing Address - Street 2:
Mailing Address - City:SAN MARINO
Mailing Address - State:CA
Mailing Address - Zip Code:91108-1917
Mailing Address - Country:US
Mailing Address - Phone:562-789-5577
Mailing Address - Fax:562-789-5567
Practice Address - Street 1:12291 WASHINGTON BLVD STE 304
Practice Address - Street 2:
Practice Address - City:WHITTIER
Practice Address - State:CA
Practice Address - Zip Code:90606-2551
Practice Address - Country:US
Practice Address - Phone:562-789-5577
Practice Address - Fax:562-789-5567
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2016-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG78258174400000X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G782580Medicaid
CAG15084Medicare UPIN
CA00G782580Medicaid