Healthcare Provider Details

I. General information

NPI: 1467641241
Provider Name (Legal Business Name): MARK NAZARIAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2007
Last Update Date: 10/17/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

460 N ELM ST
ESCONDIDO CA
92025-3002
US

IV. Provider business mailing address

425 N DATE ST
ESCONDIDO CA
92025-3413
US

V. Phone/Fax

Practice location:
  • Phone: 760-520-8100
  • Fax: 760-737-2039
Mailing address:
  • Phone: 760-735-2035
  • Fax: 760-520-8314

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberG63835
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: