Provider Demographics
NPI:1811376908
Name:WASHINGTON, VANCE MARSHAL (MD)
Entity Type:Individual
Prefix:
First Name:VANCE
Middle Name:MARSHAL
Last Name:WASHINGTON
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 1:5767 W CENTURY BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-5631
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4560 ADMIRALTY WAY STE 100
Practice Address - Street 2:
Practice Address - City:MARINA DEL REY
Practice Address - State:CA
Practice Address - Zip Code:90292-5424
Practice Address - Country:US
Practice Address - Phone:310-827-3700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-22
Last Update Date:2023-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV18832207Q00000X
AL38022207Q00000X
CAC187365207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1811376908Medicaid
NV18832OtherSTATE LICENSE