Healthcare Provider Details

I. General information

NPI: 1003664319
Provider Name (Legal Business Name): MARK SUTTON MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2024
Last Update Date: 07/16/2024
Certification Date: 07/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 S 7TH AVE STE A
BARSTOW CA
92311-3059
US

IV. Provider business mailing address

121 S 7TH AVE
BARSTOW CA
92311-3058
US

V. Phone/Fax

Practice location:
  • Phone: 760-256-1004
  • Fax: 760-256-1055
Mailing address:
  • Phone: 760-256-1004
  • Fax: 760-256-1055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MARK SUTTON
Title or Position: OWNER/PROVIDER
Credential: M.D.
Phone: 760-256-1004