Healthcare Provider Details

I. General information

NPI: 1891806014
Provider Name (Legal Business Name): MARK BURRELL BAZALGETTE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 01/22/2020
Certification Date: 01/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

165 ROWLAND WAY STE 200
NOVATO CA
94945-5055
US

IV. Provider business mailing address

5 BON AIR RD SUITE 101
LARKSPUR CA
94939-1143
US

V. Phone/Fax

Practice location:
  • Phone: 415-827-0344
  • Fax: 415-924-2661
Mailing address:
  • Phone: 415-924-2515
  • Fax: 415-924-2661

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License NumberA46290
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: