Provider Demographics
NPI:1427380070
Name:MARC H. SHOMER, MD, PHD, INC
Entity Type:Organization
Organization Name:MARC H. SHOMER, MD, PHD, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MARC
Authorized Official - Middle Name:HOWARD
Authorized Official - Last Name:SHOMER
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PHD
Authorized Official - Phone:909-636-8586
Mailing Address - Street 1:PO BOX 1075
Mailing Address - Street 2:
Mailing Address - City:DANA POINT
Mailing Address - State:CA
Mailing Address - Zip Code:92629-5075
Mailing Address - Country:US
Mailing Address - Phone:909-981-9800
Mailing Address - Fax:909-946-3937
Practice Address - Street 1:820 N MOUNTAIN AVE STE 102
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-4163
Practice Address - Country:US
Practice Address - Phone:909-981-9800
Practice Address - Fax:909-946-3937
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-08
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA95190261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACZ142AOtherMEDICARE PTAN