Basic Information
| Provider Information | |||||||||
| NPI: | 1548419518 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MARIE MBOUNI M.D A MEDICAL CORPORATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 S 1ST ST | ||||||||
| Address2: | SUITE #1000 | ||||||||
| City: | BURBANK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 915021938 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8188456206 | ||||||||
| FaxNumber: | 8188459774 | ||||||||
| Practice Location | |||||||||
| Address1: | 3751 KATELLA AVE | ||||||||
| Address2: | |||||||||
| City: | LOS ALAMITOS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 907203101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5627993160 | ||||||||
| FaxNumber: | 5627993133 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2008 | ||||||||
| LastUpdateDate: | 12/30/2008 | ||||||||
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| AuthorizedOfficialLastName: | MBOUNI-ESSOMBA | ||||||||
| AuthorizedOfficialFirstName: | MARIE | ||||||||
| AuthorizedOfficialMiddleName: | T. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2182333421 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | C52701 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 00C527010 | 01 | CA | BLUE SHIELD | OTHER |