Provider Demographics
NPI:1851713002
Name:MARK LYMAN MAGULAC M.D., A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:MARK LYMAN MAGULAC M.D., A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:MAGULAC
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:858-487-3330
Mailing Address - Street 1:PO BOX 511267
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90051-7822
Mailing Address - Country:US
Mailing Address - Phone:866-284-2771
Mailing Address - Fax:800-334-1041
Practice Address - Street 1:11440 W BERNARDO CT
Practice Address - Street 2:SUITE 300
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92127-1641
Practice Address - Country:US
Practice Address - Phone:858-487-3330
Practice Address - Fax:858-487-3331
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-07
Last Update Date:2014-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG561572084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty