Provider Demographics
NPI:1881610905
Name:DEREZIN, MARVIN (MD)
Entity type:Individual
Prefix:
First Name:MARVIN
Middle Name:
Last Name:DEREZIN
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 1:5767 W CENTURY BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-5632
Mailing Address - Country:US
Mailing Address - Phone:310-794-1700
Mailing Address - Fax:
Practice Address - Street 1:200 MEDICAL PLAZA
Practice Address - Street 2:#365
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-3075
Practice Address - Country:US
Practice Address - Phone:310-794-1700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2013-03-11
Deactivation Date:2012-11-19
Deactivation Code:
Reactivation Date:2013-03-11
Provider Licenses
StateLicense IDTaxonomies
CAG11139207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G111390Medicaid
CAWG11139AMedicare PIN
CA00G111390Medicaid
CAWG11139BMedicare PIN
CAWG11139CMedicare PIN