Provider Demographics
NPI:1245442714
Name:BLACK, MARLON DEAN (MD)
Entity type:Individual
Prefix:
First Name:MARLON
Middle Name:DEAN
Last Name:BLACK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:M.
Other - Middle Name:DEAN
Other - Last Name:BLACK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:DEPT LA 21613
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91185-1613
Mailing Address - Country:US
Mailing Address - Phone:949-263-8620
Mailing Address - Fax:949-263-1639
Practice Address - Street 1:2320 BATH STREET SUITE 208
Practice Address - Street 2:
Practice Address - City:SANTA BARBARA
Practice Address - State:CA
Practice Address - Zip Code:93105-5322
Practice Address - Country:US
Practice Address - Phone:805-682-7984
Practice Address - Fax:805-569-2964
Is Sole Proprietor?:No
Enumeration Date:2007-05-04
Last Update Date:2022-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA848222085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A848220Medicaid
CA00A848220OtherBS
CA00A848220Medicaid
CAWA84822DMedicare PIN
CAAW727YMedicare PIN
CAAW727WMedicare PIN
CA00A848220OtherBS
CAAW727XMedicare PIN
CAWA84822AMedicare PIN