Provider Demographics
NPI:1780857185
Name:MARVIN J. TEITELBAUM, MD, PROF CORP
Entity Type:Organization
Organization Name:MARVIN J. TEITELBAUM, MD, PROF CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:TEITELBAUM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-828-3401
Mailing Address - Street 1:2901 WILSHIRE BLVD
Mailing Address - Street 2:SUITE # 230
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90403-4901
Mailing Address - Country:US
Mailing Address - Phone:310-828-3401
Mailing Address - Fax:
Practice Address - Street 1:2901 WILSHIRE BLVD
Practice Address - Street 2:SUITE # 230
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90403-4901
Practice Address - Country:US
Practice Address - Phone:310-828-3401
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-07
Last Update Date:2012-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA21993Medicare PIN