Provider Demographics
NPI:1245292085
Name:MAHAN, MARCELLE (MD)
Entity type:Individual
Prefix:
First Name:MARCELLE
Middle Name:
Last Name:MAHAN
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:PO BOX 2717
Mailing Address - Street 2:
Mailing Address - City:MCKINLEYVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95519-2717
Mailing Address - Country:US
Mailing Address - Phone:707-499-8781
Mailing Address - Fax:
Practice Address - Street 1:2700 DOLBEER ST
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95501-4736
Practice Address - Country:US
Practice Address - Phone:707-269-4250
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-05
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG71860207P00000X
CAG078160208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G718600Medicaid
CA00G718600Medicaid
CAF10320Medicare UPIN