Basic Information
| Provider Information | |||||||||
| NPI: | 1851713002 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MARK LYMAN MAGULAC M.D., A PROFESSIONAL CORPORATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 511267 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900517822 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8662842771 | ||||||||
| FaxNumber: | 8003341041 | ||||||||
| Practice Location | |||||||||
| Address1: | 11440 W BERNARDO CT | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921271641 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8584873330 | ||||||||
| FaxNumber: | 8584873331 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/07/2014 | ||||||||
| LastUpdateDate: | 01/07/2014 | ||||||||
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| AuthorizedOfficialLastName: | MAGULAC | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8584873330 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | G56157 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.