Provider Demographics
NPI:1104128941
Name:LARRY MARIANELLA, MD A PROFESSIONAL CORP.
Entity type:Organization
Organization Name:LARRY MARIANELLA, MD A PROFESSIONAL CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:MARIANELLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:707-526-4865
Mailing Address - Street 1:1515 MONTGOMERY DR
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-4500
Mailing Address - Country:US
Mailing Address - Phone:707-526-4865
Mailing Address - Fax:707-526-5375
Practice Address - Street 1:1515 MONTGOMERY DR
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-4500
Practice Address - Country:US
Practice Address - Phone:707-526-4865
Practice Address - Fax:707-526-5375
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-30
Last Update Date:2010-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG38835207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G388351Medicaid
CA00G388351Medicaid
CAA47615Medicare UPIN