Provider Demographics
NPI:1720064165
Name:MARCUS, MICHAEL J (DPM)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:MARCUS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:A
Other - Middle Name:PROFESSIONAL
Other - Last Name:CORPORATION
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:101 E BEVERLY BLVD
Mailing Address - Street 2:STE 205
Mailing Address - City:MONTEBELLO
Mailing Address - State:CA
Mailing Address - Zip Code:90640-4315
Mailing Address - Country:US
Mailing Address - Phone:323-724-6663
Mailing Address - Fax:323-724-5816
Practice Address - Street 1:101 E BEVERLY BLVD
Practice Address - Street 2:SUITE 205
Practice Address - City:MONTEBELLO
Practice Address - State:CA
Practice Address - Zip Code:90640-4315
Practice Address - Country:US
Practice Address - Phone:323-724-6663
Practice Address - Fax:323-724-5816
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-19
Last Update Date:2017-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE1928213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1720064165Medicaid
CAT11098Medicare UPIN
CA0513220001Medicare NSC
CACD665YMedicare PIN