Provider Demographics
NPI:1063524528
Name:MARIANO, ELPIDIO C (MD)
Entity type:Individual
Prefix:DR
First Name:ELPIDIO
Middle Name:C
Last Name:MARIANO
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:106 LYNCH CREEK WAY
Mailing Address - Street 2:SUITE 9B
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94954-2356
Mailing Address - Country:US
Mailing Address - Phone:707-763-1575
Mailing Address - Fax:707-763-9172
Practice Address - Street 1:106 LYNCH CREEK WAY
Practice Address - Street 2:SUITE 9B
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94954-2356
Practice Address - Country:US
Practice Address - Phone:707-763-1575
Practice Address - Fax:707-763-9172
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2010-09-14
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAA39817208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A398170Medicaid
00A398170Medicare ID - Type Unspecified
A28972Medicare UPIN