Healthcare Provider Details

I. General information

NPI: 1528158664
Provider Name (Legal Business Name): MARK AUGUSTO VENTOCILLA OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 03/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

613 E GRAND AVE
ESCONDIDO CA
92025-4402
US

IV. Provider business mailing address

613 E GRAND AVE
ESCONDIDO CA
92025-4402
US

V. Phone/Fax

Practice location:
  • Phone: 760-747-4797
  • Fax: 760-747-7799
Mailing address:
  • Phone: 760-747-7979
  • Fax: 760-747-7799

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4901003734
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPC 3532
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number10435
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: