Provider Demographics
NPI:1891291423
Name:FAM, MARIAN (MD)
Entity Type:Individual
Prefix:
First Name:MARIAN
Middle Name:
Last Name:FAM
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 1:4244 RIVERWALK PKWY STE 290
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92505-8509
Mailing Address - Country:US
Mailing Address - Phone:559-765-9515
Mailing Address - Fax:
Practice Address - Street 1:4244 RIVERWALK PKWY STE 290
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92505-8509
Practice Address - Country:US
Practice Address - Phone:951-520-9392
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-03
Last Update Date:2022-03-23
Deactivation Date:2021-12-12
Deactivation Code:
Reactivation Date:2022-03-22
Provider Licenses
StateLicense IDTaxonomies
CAA174623207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty