Provider Demographics
NPI: | 1013974393 |
---|---|
Name: | MARANDOLA, MICHAEL S (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | MICHAEL |
Middle Name: | S |
Last Name: | MARANDOLA |
Suffix: | |
Gender: | M |
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: | 26401 CROWN VALLEY PKWY |
Mailing Address - Street 2: | SUITE 101 |
Mailing Address - City: | MISSION VIEJO |
Mailing Address - State: | CA |
Mailing Address - Zip Code: | 92691-6302 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 949-348-4000 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 26401 CROWN VALLEY PKWY |
Practice Address - Street 2: | SUITE 101 |
Practice Address - City: | MISSION VIEJO |
Practice Address - State: | CA |
Practice Address - Zip Code: | 92691-6302 |
Practice Address - Country: | US |
Practice Address - Phone: | 949-348-4000 |
Practice Address - Fax: | |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-04-28 |
Last Update Date: | 2023-03-07 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
CA | G64377 | 207XX0005X, 207X00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207X00000X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | |
No | 207XX0005X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
CA | BM1658092 | Other | DEA |
CA | F11702 | Medicare UPIN | |
CA | WG64377B | Medicare PIN |