Provider Demographics
NPI:1417456104
Name:KRAIDMAN, MARC IAN
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:IAN
Last Name:KRAIDMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23301 SUNNYVALE CT
Mailing Address - Street 2:
Mailing Address - City:VALENCIA
Mailing Address - State:CA
Mailing Address - Zip Code:91354-1469
Mailing Address - Country:US
Mailing Address - Phone:661-309-5111
Mailing Address - Fax:
Practice Address - Street 1:1725 HILLSDALE RD
Practice Address - Street 2:
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92019-3743
Practice Address - Country:US
Practice Address - Phone:661-309-5111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-08
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE127837146N00000X
146N00000X, 390200000X
20000330022255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer