Provider Demographics
NPI:1548395742
Name:ANDERSON, MARCEL DWAYNE
Entity Type:Individual
Prefix:MR
First Name:MARCEL
Middle Name:DWAYNE
Last Name:ANDERSON
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 1:411 E 17TH ST APT 3
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94606-1869
Mailing Address - Country:US
Mailing Address - Phone:510-274-0959
Mailing Address - Fax:
Practice Address - Street 1:3695 HIGH ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94619-2105
Practice Address - Country:US
Practice Address - Phone:510-434-7990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator