Provider Demographics
NPI:1801972302
Name:MELVYN H. KRAUSE, M. D. AND JOHN J. DI MARE JR., M.D., INC.
Entity type:Organization
Organization Name:MELVYN H. KRAUSE, M. D. AND JOHN J. DI MARE JR., M.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MELVYN
Authorized Official - Middle Name:HOWARD
Authorized Official - Last Name:KRAUSE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-963-4149
Mailing Address - Street 1:210 S. GRAND AVENUE
Mailing Address - Street 2:SUITE 302
Mailing Address - City:GLENDORA
Mailing Address - State:CA
Mailing Address - Zip Code:91741
Mailing Address - Country:US
Mailing Address - Phone:626-963-4149
Mailing Address - Fax:626-963-9023
Practice Address - Street 1:210 S. GRAND AVENUE
Practice Address - Street 2:SUITE 302
Practice Address - City:GLENDORA
Practice Address - State:CA
Practice Address - Zip Code:91741
Practice Address - Country:US
Practice Address - Phone:626-963-4149
Practice Address - Fax:626-963-9023
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00A182340174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA21251Medicare UPIN
CAWA18234AMedicare ID - Type Unspecified