Provider Demographics
NPI:1457621666
Name:JASON J MARENGO MD INC
Entity Type:Organization
Organization Name:JASON J MARENGO MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWENER
Authorized Official - Prefix:MR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:J
Authorized Official - Last Name:MARENGO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-501-9831
Mailing Address - Street 1:PO BOX 2578
Mailing Address - Street 2:
Mailing Address - City:SEAL BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90740-2578
Mailing Address - Country:US
Mailing Address - Phone:714-501-9831
Mailing Address - Fax:
Practice Address - Street 1:3055 W ORANGE AVE STE 103
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92804-3152
Practice Address - Country:US
Practice Address - Phone:714-995-2901
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-04
Last Update Date:2012-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA=========OtherMEDICAL LICENSE A82346