Provider Demographics
NPI:1447327507
Name:MARINCOVICH, PETER JANSEN (PHD AUDIOLOGIST DISP)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:JANSEN
Last Name:MARINCOVICH
Suffix:
Gender:M
Credentials:PHD AUDIOLOGIST DISP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 SONOMA AVENUE
Mailing Address - Street 2:SUITE 316
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405
Mailing Address - Country:US
Mailing Address - Phone:707-523-4740
Mailing Address - Fax:707-523-0231
Practice Address - Street 1:1111 SONOMA AVENUE
Practice Address - Street 2:SUITE 316
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405
Practice Address - Country:US
Practice Address - Phone:707-523-4740
Practice Address - Fax:707-523-0231
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2013-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAU758231H00000X
CAHA1949237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAU0007580Medicaid
CAZZZ03361ZOtherBLUE SHIELD
CA640002077OtherRRM
CAZZZ03362ZOtherBLUE SHIELD
CAZZZ03362ZOtherBLUE SHIELD