Provider Demographics
NPI:1184716458
Name:LAXA, MARYANNE IAN (MD)
Entity type:Individual
Prefix:MRS
First Name:MARYANNE
Middle Name:IAN
Last Name:LAXA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:91275 66TH ST
Mailing Address - Street 2:
Mailing Address - City:MECCA
Mailing Address - State:CA
Mailing Address - Zip Code:92254
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:91275 66TH ST
Practice Address - Street 2:
Practice Address - City:MECCA
Practice Address - State:CA
Practice Address - Zip Code:92254
Practice Address - Country:US
Practice Address - Phone:760-344-9951
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2012-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA764092080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A764090Medicaid