Provider Demographics
NPI:1457332975
Name:MARIANO, MYRON C (MD)
Entity Type:Individual
Prefix:
First Name:MYRON
Middle Name:C
Last Name:MARIANO
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 1:412 W CARROLL AVE
Mailing Address - Street 2:SUITE 106
Mailing Address - City:GLENDORA
Mailing Address - State:CA
Mailing Address - Zip Code:91741-4240
Mailing Address - Country:US
Mailing Address - Phone:626-963-6026
Mailing Address - Fax:626-963-5094
Practice Address - Street 1:412 W CARROLL AVE
Practice Address - Street 2:SUITE 106
Practice Address - City:GLENDORA
Practice Address - State:CA
Practice Address - Zip Code:91741-4240
Practice Address - Country:US
Practice Address - Phone:626-963-6026
Practice Address - Fax:626-963-5094
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-10
Last Update Date:2023-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL6241208600000X
CAG79760208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX16100901Medicaid
TXH08256Medicare UPIN
TX8A8071Medicare ID - Type Unspecified