Healthcare Provider Details

I. General information

NPI: 1205166014
Provider Name (Legal Business Name): MARK MADISON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/30/2009
Last Update Date: 04/05/2023
Certification Date: 04/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2535 KETTNER BLVD SUITE 1A4
SAN DIEGO CA
92101-1250
US

IV. Provider business mailing address

5650 MOUNT ACKERLY DR
SAN DIEGO CA
92111-4016
US

V. Phone/Fax

Practice location:
  • Phone: 619-615-0701
  • Fax: 619-615-0705
Mailing address:
  • Phone: 619-254-8980
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: