Provider Demographics
NPI:1831116474
Name:MBOUNI-ESSOMBA, MARIE (MD)
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:
Last Name:MBOUNI-ESSOMBA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:728 MONTEREY BLVD
Mailing Address - Street 2:
Mailing Address - City:HERMOSA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90254-4549
Mailing Address - Country:US
Mailing Address - Phone:310-779-4972
Mailing Address - Fax:
Practice Address - Street 1:3751 KATELLA AVENUE
Practice Address - Street 2:LOS ALAMITOS MEDICAL CENTER
Practice Address - City:LOS ALAMITOS
Practice Address - State:CA
Practice Address - Zip Code:90720
Practice Address - Country:US
Practice Address - Phone:310-779-4972
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2014-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND9080207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABB542YMedicare PIN
H72981Medicare UPIN
CABB542ZMedicare PIN