Provider Demographics
NPI:1609399591
Name:MARVASO, CAITLIN ROSE
Entity Type:Individual
Prefix:
First Name:CAITLIN
Middle Name:ROSE
Last Name:MARVASO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2540 CHARLESTON ST
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94602-2508
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2540 CHARLESTON ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94602-2508
Practice Address - Country:US
Practice Address - Phone:510-531-7551
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-21
Last Update Date:2017-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA97367914CMedicaid