Healthcare Provider Details

I. General information

NPI: 1295027613
Provider Name (Legal Business Name): MARK VENTOCILLA, O.D., INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2011
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: 760-747-7979
  • Fax: 760-747-7799
Mailing address:
  • Phone: 760-747-7979
  • Fax: 760-747-7799

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number10435
License Number StateCA

VIII. Authorized Official

Name: DR. MARK AUGUSTO VENTOCILLA
Title or Position: OWNER
Credential: OD
Phone: 616-502-0069