Provider Demographics
NPI:1215925409
Name:MANVELYAN, MARINA E (MD)
Entity type:Individual
Prefix:
First Name:MARINA
Middle Name:E
Last Name:MANVELYAN
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 1:2544 E WASHINGTON BLVD
Mailing Address - Street 2:SUITE 3
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91107-1449
Mailing Address - Country:US
Mailing Address - Phone:626-798-1085
Mailing Address - Fax:626-798-9041
Practice Address - Street 1:2544 E WASHINGTON BLVD
Practice Address - Street 2:SUITE 3
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91107-1449
Practice Address - Country:US
Practice Address - Phone:626-798-1085
Practice Address - Fax:626-798-9041
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-11
Last Update Date:2010-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA055018207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A550180Medicaid
G62693Medicare UPIN
A55018Medicare ID - Type Unspecified