Healthcare Provider Details

I. General information

NPI: 1932329265
Provider Name (Legal Business Name): MARK LAVERNE JANZEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/27/2007
Last Update Date: 01/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10800 MAGNOLIA AVENUE, KAISER PERMANENTE RIVERSIDE MEDICAL CENTER
RIVERSIDE CA
92505
US

IV. Provider business mailing address

10800 MAGNOLIA AVENUE, MOB1, 2ND FLOOR, MODULE 216 KAISER PERMANENTE RIVERSIDE MEDICAL CENTER
RIVERSIDE CA
92505
US

V. Phone/Fax

Practice location:
  • Phone: 440-781-0931
  • Fax:
Mailing address:
  • Phone: 440-781-0931
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number089484
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License Number089484
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberA90203
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: