Provider Demographics
NPI:1417061714
Name:MARCUS, DANIEL R (MD)
Entity Type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:R
Last Name:MARCUS
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:PO BOX 66459
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90066-0459
Mailing Address - Country:US
Mailing Address - Phone:310-305-1813
Mailing Address - Fax:310-821-3555
Practice Address - Street 1:4640 ADMIRALTY WAY STE 1020
Practice Address - Street 2:
Practice Address - City:MARINA DEL REY
Practice Address - State:CA
Practice Address - Zip Code:90292-6641
Practice Address - Country:US
Practice Address - Phone:310-305-1813
Practice Address - Fax:310-821-3555
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-17
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC51003174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC51003OtherMEDICAL LICENSE