Provider Demographics
NPI:1740373315
Name:MARKS, GUSTAVO (MD)
Entity type:Individual
Prefix:
First Name:GUSTAVO
Middle Name:
Last Name:MARKS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 27206
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90027-0206
Mailing Address - Country:US
Mailing Address - Phone:213-385-0675
Mailing Address - Fax:213-365-6429
Practice Address - Street 1:22030 SHERMAN WAY STE 318
Practice Address - Street 2:
Practice Address - City:CANOGA PARK
Practice Address - State:CA
Practice Address - Zip Code:91303-1886
Practice Address - Country:US
Practice Address - Phone:818-999-5900
Practice Address - Fax:818-999-5901
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2012-12-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA54483207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA54483Medicare PIN