Provider Demographics
NPI:1811034135
Name:MARK R. PULERA, MD, A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:MARK R. PULERA, MD, A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:RONALD
Authorized Official - Last Name:PULERA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-823-7800
Mailing Address - Street 1:4644 LINCOLN BLVD
Mailing Address - Street 2:SUITE 404
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90292-6313
Mailing Address - Country:US
Mailing Address - Phone:310-823-7800
Mailing Address - Fax:
Practice Address - Street 1:4644 LINCOLN BLVD
Practice Address - Street 2:SUITE 404
Practice Address - City:MARINA DEL REY
Practice Address - State:CA
Practice Address - Zip Code:90292-6313
Practice Address - Country:US
Practice Address - Phone:310-823-7800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2008-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG0816952084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
G72731Medicare UPIN
CAG81695Medicare ID - Type Unspecified