Provider Demographics
NPI:1700804887
Name:MARRIOTT, ROBERT (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:MARRIOTT
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 1:222 N PACIFIC COAST HWY STE 2175
Mailing Address - Street 2:
Mailing Address - City:EL SEGUNDO
Mailing Address - State:CA
Mailing Address - Zip Code:90245-5639
Mailing Address - Country:US
Mailing Address - Phone:877-878-3289
Mailing Address - Fax:877-817-3227
Practice Address - Street 1:222 N PACIFIC COAST HWY STE 2175
Practice Address - Street 2:
Practice Address - City:EL SEGUNDO
Practice Address - State:CA
Practice Address - Zip Code:90245-5639
Practice Address - Country:US
Practice Address - Phone:877-878-3289
Practice Address - Fax:877-817-3227
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2019-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA92018208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA92018OtherMEDICAL LICIENSE
CA00A920180Medicare PIN
CAA92018OtherMEDICAL LICIENSE