Provider Demographics
NPI:1427085661
Name:MAGULAC, MARK LYMAN (MD)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:LYMAN
Last Name:MAGULAC
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 511267
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90051-7822
Mailing Address - Country:US
Mailing Address - Phone:866-284-2771
Mailing Address - Fax:800-334-1041
Practice Address - Street 1:11440 W BERNARDO CT
Practice Address - Street 2:SUITE 300
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92127-1641
Practice Address - Country:US
Practice Address - Phone:858-487-3330
Practice Address - Fax:858-487-3331
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2019-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG561572084P0804X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
H20751Medicare UPIN
CAWG56157AMedicare ID - Type Unspecified