Healthcare Provider Details

I. General information

NPI: 1801898929
Provider Name (Legal Business Name): MARK J FREEMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2005
Last Update Date: 04/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15322 LAKESHORE DR STE 101
CLEARLAKE CA
95422-9815
US

IV. Provider business mailing address

15322 LAKESHORE DR STE 101
CLEARLAKE CA
95422-9815
US

V. Phone/Fax

Practice location:
  • Phone: 707-995-1362
  • Fax: 707-995-7057
Mailing address:
  • Phone: 707-995-1362
  • Fax: 707-995-7057

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberG47688
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: