Provider Demographics
NPI:1740393446
Name:PIETRUSZKA, MARVIN (MD)
Entity Type:Individual
Prefix:MR
First Name:MARVIN
Middle Name:
Last Name:PIETRUSZKA
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 1:19234 VANOWEN ST
Mailing Address - Street 2:
Mailing Address - City:RESEDA
Mailing Address - State:CA
Mailing Address - Zip Code:91335-5000
Mailing Address - Country:US
Mailing Address - Phone:310-914-9150
Mailing Address - Fax:310-914-9705
Practice Address - Street 1:19234 VANOWEN ST
Practice Address - Street 2:
Practice Address - City:RESEDA
Practice Address - State:CA
Practice Address - Zip Code:91335-5000
Practice Address - Country:US
Practice Address - Phone:310-914-9150
Practice Address - Fax:310-914-9705
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA30858207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A308580Medicaid
CAA26259Medicare UPIN
CA00A308580Medicaid