Provider Demographics
NPI:1366694606
Name:KREMER PRILL, MARNIE JO (MD)
Entity Type:Individual
Prefix:
First Name:MARNIE
Middle Name:JO
Last Name:KREMER PRILL
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 1:471 N. OLD NEWPORT #302
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92633-4244
Mailing Address - Country:US
Mailing Address - Phone:949-645-3534
Mailing Address - Fax:
Practice Address - Street 1:ONE HOAG DRIVE
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-4162
Practice Address - Country:US
Practice Address - Phone:949-645-3534
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-17
Last Update Date:2015-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA1093582085R0202X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1366694606Medicaid
CA00A10935800OtherBCBS OF CA
CACB224170Medicare PIN
CACB225439Medicare PIN