Provider Demographics
NPI:1679676597
Name:MARMOLEJO, AMANDA (MD)
Entity Type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:
Last Name:MARMOLEJO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 N TUSTIN AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-3807
Mailing Address - Country:US
Mailing Address - Phone:714-347-1010
Mailing Address - Fax:714-647-1245
Practice Address - Street 1:3333 W COAST HWY STE 100
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-4087
Practice Address - Country:US
Practice Address - Phone:949-645-6272
Practice Address - Fax:949-999-0151
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG57535207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G575350Medicaid
CAC18807Medicare UPIN