Healthcare Provider Details

I. General information

NPI: 1124866959
Provider Name (Legal Business Name): AMPLIFY PHYSICIANS OF CALIFORNIA PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2024
Last Update Date: 07/16/2024
Certification Date: 07/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4403 S VERMONT AVE
LOS ANGELES CA
90037-2413
US

IV. Provider business mailing address

6125 LUTHER LN # 572
DALLAS TX
75225-6202
US

V. Phone/Fax

Practice location:
  • Phone: 323-232-1234
  • Fax:
Mailing address:
  • Phone: 312-608-4584
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DAVID BRUCE MARK
Title or Position: OWNER
Credential: MD
Phone: 408-739-6200