Provider Demographics
NPI:1992731830
Name:CORREN, MARSHALL HOWARD (MD)
Entity type:Individual
Prefix:DR
First Name:MARSHALL
Middle Name:HOWARD
Last Name:CORREN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1828 S WESTERN AVE
Mailing Address - Street 2:#10
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90006-5808
Mailing Address - Country:US
Mailing Address - Phone:323-730-0310
Mailing Address - Fax:323-730-1335
Practice Address - Street 1:1828 S WESTERN AVE
Practice Address - Street 2:#10
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90006-5808
Practice Address - Country:US
Practice Address - Phone:323-730-0310
Practice Address - Fax:323-730-1335
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA25663174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF83756Medicare UPIN
CAWA25663DMedicare ID - Type Unspecified
CAW13240BMedicare ID - Type UnspecifiedGROUP ID