Provider Demographics
NPI:1275591349
Name:GRADITOR, MARSHALL MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:MARSHALL
Middle Name:MICHAEL
Last Name:GRADITOR
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 1:7345 MEDICAL CENTER DR
Mailing Address - Street 2:SUITE #320
Mailing Address - City:WEST HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91307-1910
Mailing Address - Country:US
Mailing Address - Phone:818-704-7766
Mailing Address - Fax:818-704-5307
Practice Address - Street 1:7345 MEDICAL CENTER DR
Practice Address - Street 2:SUITE #320
Practice Address - City:WEST HILLS
Practice Address - State:CA
Practice Address - Zip Code:91307-1910
Practice Address - Country:US
Practice Address - Phone:818-704-7766
Practice Address - Fax:818-704-5307
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2010-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG38911174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG38911Medicare ID - Type UnspecifiedLICENSE NUMBER
CAA92031Medicare UPIN