Provider Demographics
NPI:1871543710
Name:MYHRE, CANDICE TIFFANY (MD)
Entity type:Individual
Prefix:DR
First Name:CANDICE
Middle Name:TIFFANY
Last Name:MYHRE
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 1:201 44TH STREET
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90266
Mailing Address - Country:US
Mailing Address - Phone:310-944-2623
Mailing Address - Fax:
Practice Address - Street 1:4650 LINCOLN BLVD
Practice Address - Street 2:DANIEL FREEMAN MARINA HOSPITAL ED
Practice Address - City:MARINA DEL REY
Practice Address - State:CA
Practice Address - Zip Code:90292
Practice Address - Country:US
Practice Address - Phone:310-822-6005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA789420207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
00A789420OtherBLUE SHIELD
CA00A789420Medicaid
CA00A789420Medicaid
CAWA78942BMedicare PIN