Provider Demographics
NPI:1114976149
Name:MARINE, MICHELLE A (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:A
Last Name:MARINE
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 1:77 ROLLING OAKS DR
Mailing Address - Street 2:306
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91361-1011
Mailing Address - Country:US
Mailing Address - Phone:805-371-8775
Mailing Address - Fax:805-379-3711
Practice Address - Street 1:77 ROLLING OAKS DR
Practice Address - Street 2:306
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91361-1011
Practice Address - Country:US
Practice Address - Phone:805-371-8775
Practice Address - Fax:805-379-3711
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-08
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG69257174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABM2558700OtherDEA NUMBER
CAW14051Medicare ID - Type UnspecifiedGROUP PROVIDER ID
CAF32545Medicare UPIN