Provider Demographics
NPI:1902108145
Name:GANDARA, MARLA M (MD)
Entity type:Individual
Prefix:
First Name:MARLA
Middle Name:M
Last Name:GANDARA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:4140 W 190TH ST
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90504-5513
Mailing Address - Country:US
Mailing Address - Phone:310-423-9520
Mailing Address - Fax:310-423-9525
Practice Address - Street 1:501 S BUENA VISTA ST
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91505-4809
Practice Address - Country:US
Practice Address - Phone:818-847-4055
Practice Address - Fax:818-848-4320
Is Sole Proprietor?:No
Enumeration Date:2010-11-19
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA115486207P00000X, 207PH0002X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PH0002XAllopathic & Osteopathic PhysiciansEmergency MedicineHospice and Palliative Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA115486OtherMEDICAL LICENSE