Provider Demographics
NPI:1477531689
Name:FINE, MARJORIE B (MD)
Entity type:Individual
Prefix:
First Name:MARJORIE
Middle Name:B
Last Name:FINE
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 1:2021 SANTA MONICA BLVD
Mailing Address - Street 2:STE 625 E
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-2208
Mailing Address - Country:US
Mailing Address - Phone:310-453-8838
Mailing Address - Fax:310-453-8355
Practice Address - Street 1:1417 N KENTER AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90049-1321
Practice Address - Country:US
Practice Address - Phone:310-472-7481
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-06
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG33019208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
W1533Medicare ID - Type Unspecified
A91491Medicare UPIN
CAHJ565ZMedicare PIN