Healthcare Provider Details

I. General information

NPI: 1548322381
Provider Name (Legal Business Name): MARK S HUMAYUN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2006
Last Update Date: 11/27/2023
Certification Date: 08/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1450 SAN PABLO ST SUITE 4000
LOS ANGELES CA
90033-4668
US

IV. Provider business mailing address

PO BOX 31309
LOS ANGELES CA
90031-0309
US

V. Phone/Fax

Practice location:
  • Phone: 323-442-6311
  • Fax: 323-442-7166
Mailing address:
  • Phone: 323-442-7152
  • Fax: 323-442-7166

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberA52637
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: