Healthcare Provider Details

I. General information

NPI: 1154327518
Provider Name (Legal Business Name): MARK IKE DEBRUIN D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2005
Last Update Date: 09/18/2012
Certification Date:
Deactivation Date: 03/21/2006
Reactivation Date: 04/11/2006

III. Provider practice location address

9352 MADISON AVE STE 1
ORANGEVALE CA
95662-4968
US

IV. Provider business mailing address

9352 MADISON AVE STE 1
ORANGEVALE CA
95662-4968
US

V. Phone/Fax

Practice location:
  • Phone: 916-989-2929
  • Fax: 916-989-0322
Mailing address:
  • Phone: 916-989-2929
  • Fax: 916-989-0322

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20A5579
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: