Healthcare Provider Details

I. General information

NPI: 1730600388
Provider Name (Legal Business Name): MARK WILLIAM RALPH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2017
Last Update Date: 08/12/2020
Certification Date: 08/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

808 W 58TH ST
LOS ANGELES CA
90037-3632
US

IV. Provider business mailing address

808 W 58TH ST
LOS ANGELES CA
90037-3632
US

V. Phone/Fax

Practice location:
  • Phone: 323-541-1411
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301113221
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number169633
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: