Healthcare Provider Details

I. General information

NPI: 1598821811
Provider Name (Legal Business Name): MARK WAYNE SURREY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/29/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 N ROXBURY DR STE 500
BEVERLY HILLS CA
90210-4226
US

IV. Provider business mailing address

450 N ROXBURY DR STE 500
BEVERLY HILLS CA
90210-4226
US

V. Phone/Fax

Practice location:
  • Phone: 310-277-2393
  • Fax: 310-274-5112
Mailing address:
  • Phone: 310-277-2393
  • Fax: 310-274-5112

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberG25146
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: