Provider Demographics
NPI:1275565608
Name:KERNER, MARC M (MD)
Entity Type:Individual
Prefix:DR
First Name:MARC
Middle Name:M
Last Name:KERNER
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 1:18350 ROSCOE BLVD STE 318
Mailing Address - Street 2:
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91325-4164
Mailing Address - Country:US
Mailing Address - Phone:818-349-0600
Mailing Address - Fax:818-993-0937
Practice Address - Street 1:18350 ROSCOE BLVD STE 318
Practice Address - Street 2:
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91325-4164
Practice Address - Country:US
Practice Address - Phone:818-349-0600
Practice Address - Fax:818-993-0937
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2009-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG69740174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95-4561883OtherTAX ID#
CA95-4561883OtherTAX ID#
CAG69740Medicare ID - Type Unspecified
CAG04276Medicare PIN