Provider Demographics
NPI:1366848335
Name:MARCO, NOACHIM (MD)
Entity Type:Individual
Prefix:
First Name:NOACHIM
Middle Name:
Last Name:MARCO
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 1:7150 TAMPA AVE
Mailing Address - Street 2:
Mailing Address - City:RESEDA
Mailing Address - State:CA
Mailing Address - Zip Code:91335-3700
Mailing Address - Country:US
Mailing Address - Phone:818-774-3032
Mailing Address - Fax:818-774-5919
Practice Address - Street 1:18855 VICTORY BLVD
Practice Address - Street 2:
Practice Address - City:RESEDA
Practice Address - State:CA
Practice Address - Zip Code:91335-6445
Practice Address - Country:US
Practice Address - Phone:818-774-3032
Practice Address - Fax:818-774-5919
Is Sole Proprietor?:No
Enumeration Date:2014-11-18
Last Update Date:2014-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG60305207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG60305OtherCA STATE LICENSE