Provider Demographics
NPI:1790908838
Name:MARION, MICHAEL WILLIAM (AUD)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:WILLIAM
Last Name:MARION
Suffix:
Gender:M
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5800 SANTA ROSA ROAD
Mailing Address - Street 2:SANTA ROSA PLAZA #123
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93012
Mailing Address - Country:US
Mailing Address - Phone:805-482-9821
Mailing Address - Fax:805-388-2937
Practice Address - Street 1:5800 SANTA ROSA ROAD
Practice Address - Street 2:SANTA ROSA PLAZA #123
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93012
Practice Address - Country:US
Practice Address - Phone:805-482-9821
Practice Address - Fax:805-388-2937
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACAAU813231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAU0008130Medicaid
CAZZZ12340ZOtherBLUE SHIELD-HEARING AID
CAZZZ11886ZOtherBLUE SHIELD-AUDIOLOGY
CAZZZ11886ZOtherBLUE SHIELD-AUDIOLOGY