Provider Demographics
NPI:1184771594
Name:LUSSIER, MARC ROBERT
Entity type:Individual
Prefix:DR
First Name:MARC
Middle Name:ROBERT
Last Name:LUSSIER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24510 TOWN CENTER DR
Mailing Address - Street 2:SUITE #180
Mailing Address - City:VALENCIA
Mailing Address - State:CA
Mailing Address - Zip Code:91355-1337
Mailing Address - Country:US
Mailing Address - Phone:661-260-3021
Mailing Address - Fax:661-260-3394
Practice Address - Street 1:24510 TOWN CENTER DR
Practice Address - Street 2:SUITE #180
Practice Address - City:VALENCIA
Practice Address - State:CA
Practice Address - Zip Code:91355-1337
Practice Address - Country:US
Practice Address - Phone:661-260-3021
Practice Address - Fax:661-260-3394
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG73222174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF46193Medicare UPIN