Provider Demographics
NPI:1639116296
Name:MARSH, GARY E (MD)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:E
Last Name:MARSH
Suffix:
Gender:M
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:DEPT LA 23039
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91185-3039
Mailing Address - Country:US
Mailing Address - Phone:562-282-4038
Mailing Address - Fax:562-658-3397
Practice Address - Street 1:9040 TELEGRAPH RD
Practice Address - Street 2:
Practice Address - City:DOWNEY
Practice Address - State:CA
Practice Address - Zip Code:90240-2393
Practice Address - Country:US
Practice Address - Phone:562-861-0954
Practice Address - Fax:562-231-1904
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-01
Last Update Date:2011-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA20613207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
110060914OtherRAILROAD
CA00A206130Medicaid
00A206130OtherBLUE SHIELD ID #
CAWA20613QMedicare PIN
110060914OtherRAILROAD
CAWA20613NMedicare PIN
A22232Medicare UPIN
CAWA20613PMedicare PIN