Provider Demographics
NPI:1891851929
Name:MASADA, MARVIN PHILLIP (MD)
Entity Type:Individual
Prefix:
First Name:MARVIN
Middle Name:PHILLIP
Last Name:MASADA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1569 LEXANN AVE
Mailing Address - Street 2:SUITE 128
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95121-1794
Mailing Address - Country:US
Mailing Address - Phone:408-274-1654
Mailing Address - Fax:408-274-8021
Practice Address - Street 1:1569 LEXANN AVE
Practice Address - Street 2:SUITE 128
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95121-1794
Practice Address - Country:US
Practice Address - Phone:408-274-1654
Practice Address - Fax:408-274-8021
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-01
Last Update Date:2015-05-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA062906207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA9351233Medicare UPIN
CABF877AMedicare PIN