Provider Demographics
NPI:1528130333
Name:ANDERSON, MARLA R (MD)
Entity type:Individual
Prefix:
First Name:MARLA
Middle Name:R
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARLA
Other - Middle Name:
Other - Last Name:UNDERLY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:27799 MEDICAL CENTER RD STE 440
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-6400
Mailing Address - Country:US
Mailing Address - Phone:949-364-1007
Mailing Address - Fax:949-364-0317
Practice Address - Street 1:27799 MEDICAL CENTER RD STE 440
Practice Address - Street 2:
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-6400
Practice Address - Country:US
Practice Address - Phone:949-364-1007
Practice Address - Fax:949-364-0317
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2025-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036106670208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
00A865120Medicare ID - Type Unspecified
I10544Medicare UPIN
CA00A865120Medicaid