Healthcare Provider Details

I. General information

NPI: 1861949711
Provider Name (Legal Business Name): MARK MEZAK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/08/2016
Last Update Date: 02/04/2022
Certification Date: 02/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2712 TELEGRAPH AVE
BERKELEY CA
94705-1117
US

IV. Provider business mailing address

691 CASTRO ST
SAN FRANCISCO CA
94114-2556
US

V. Phone/Fax

Practice location:
  • Phone: 510-548-8283
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: