Provider Demographics
NPI:1821134891
Name:MARUMOTO, BENJAMIN K
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:K
Last Name:MARUMOTO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:745 S BREA BLVD
Mailing Address - Street 2:#21
Mailing Address - City:BREA
Mailing Address - State:CA
Mailing Address - Zip Code:92821-5365
Mailing Address - Country:US
Mailing Address - Phone:714-529-1676
Mailing Address - Fax:
Practice Address - Street 1:745 S BREA BLVD
Practice Address - Street 2:#21
Practice Address - City:BREA
Practice Address - State:CA
Practice Address - Zip Code:92821-5365
Practice Address - Country:US
Practice Address - Phone:714-529-1676
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2010-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA4522TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAT69913Medicare UPIN