Provider Demographics
NPI:1386306736
Name:MAMURIC, ETHAN-IRA B (DPT)
Entity type:Individual
Prefix:DR
First Name:ETHAN-IRA
Middle Name:B
Last Name:MAMURIC
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:360 S DETROIT ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90036-3475
Mailing Address - Country:US
Mailing Address - Phone:908-405-5947
Mailing Address - Fax:
Practice Address - Street 1:201 N ROBERTSON BLVD
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90211-1729
Practice Address - Country:US
Practice Address - Phone:424-303-7647
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-12
Last Update Date:2021-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA301131225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist