Provider Demographics
NPI:1700936150
Name:KWOLEK, MARILYN (MD)
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:
Last Name:KWOLEK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MRS
Other - First Name:JEAN
Other - Middle Name:
Other - Last Name:RIOLO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:917 SAN RAMON VALLEY BLVD
Mailing Address - Street 2:STE 199
Mailing Address - City:DANVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94526-4005
Mailing Address - Country:US
Mailing Address - Phone:925-838-8677
Mailing Address - Fax:925-685-8750
Practice Address - Street 1:917 SAN RAMON VALLEY BLVD
Practice Address - Street 2:STE 199
Practice Address - City:DANVILLE
Practice Address - State:CA
Practice Address - Zip Code:94526-4005
Practice Address - Country:US
Practice Address - Phone:925-838-8677
Practice Address - Fax:925-685-8750
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAC41932174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA680147223OtherTAX IDENTIFICATION
CAA37705Medicare UPIN
CA00C419320Medicare ID - Type Unspecified