Provider Demographics
NPI:1376540245
Name:FIRESTONE, MARVIN H (MD)
Entity Type:Individual
Prefix:
First Name:MARVIN
Middle Name:H
Last Name:FIRESTONE
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 1:1700 S EL CAMINO REAL
Mailing Address - Street 2:SUITE 204
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94402-3047
Mailing Address - Country:US
Mailing Address - Phone:650-212-4900
Mailing Address - Fax:
Practice Address - Street 1:520 S EL CAMINO REAL
Practice Address - Street 2:SUITE 310
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94402-1726
Practice Address - Country:US
Practice Address - Phone:650-212-4900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-06
Last Update Date:2013-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG1929502084F0202X, 2084P0800X, 2084P0805X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084F0202XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyForensic Psychiatry
No2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE83918Medicare UPIN