Provider Demographics
NPI:1609106467
Name:CI MARINA MEDICAL INC
Entity Type:Organization
Organization Name:CI MARINA MEDICAL INC
Other - Org Name:GARY R MITNICK DO
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:MITNICK
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:805-985-5880
Mailing Address - Street 1:4310 TRADEWINDS DR
Mailing Address - Street 2:STE 300
Mailing Address - City:OXNARD
Mailing Address - State:CA
Mailing Address - Zip Code:93035-1407
Mailing Address - Country:US
Mailing Address - Phone:805-985-5880
Mailing Address - Fax:805-984-9839
Practice Address - Street 1:4310 TRADEWINDS DR
Practice Address - Street 2:STE 300
Practice Address - City:OXNARD
Practice Address - State:CA
Practice Address - Zip Code:93035-1407
Practice Address - Country:US
Practice Address - Phone:805-985-5880
Practice Address - Fax:805-984-9839
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-29
Last Update Date:2010-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A4379207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA20A4379OtherMEDICAL LICENSE NUMBER