Provider Demographics
NPI:1053389205
Name:MARIOTTI, ERIC R (MD)
Entity type:Individual
Prefix:DR
First Name:ERIC
Middle Name:R
Last Name:MARIOTTI
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 1:2222 EAST ST
Mailing Address - Street 2:#310
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94520-2084
Mailing Address - Country:US
Mailing Address - Phone:925-685-4533
Mailing Address - Fax:952-685-0665
Practice Address - Street 1:2222 EAST ST
Practice Address - Street 2:#310
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94520-2084
Practice Address - Country:US
Practice Address - Phone:925-685-4533
Practice Address - Fax:952-685-0665
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-14
Last Update Date:2014-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG853322086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G853320Medicaid
G73734Medicare UPIN
CA00G853320Medicare ID - Type Unspecified