Provider Demographics
NPI:1205869427
Name:MARWAN EDRIS MD A PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:MARWAN EDRIS MD A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:MARWAN
Authorized Official - Middle Name:
Authorized Official - Last Name:EDRIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-364-9080
Mailing Address - Street 1:25283 CABOT RD STE 106
Mailing Address - Street 2:SUITE 106
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653-5509
Mailing Address - Country:US
Mailing Address - Phone:949-364-9080
Mailing Address - Fax:949-364-3856
Practice Address - Street 1:25283 CABOT RD STE 106
Practice Address - Street 2:SUITE 106
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-5509
Practice Address - Country:US
Practice Address - Phone:949-364-9080
Practice Address - Fax:949-364-3856
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2024-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW16626OtherMEDICARE ID NUMBER
CAA42896OtherLICENSE
CAA85836Medicare UPIN