Healthcare Provider Details

I. General information

NPI: 1841255056
Provider Name (Legal Business Name): MARK TIMOTHY MCVAY DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2006
Last Update Date: 10/15/2024
Certification Date: 10/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

260 HOSPITAL DR STE 204
UKIAH CA
95482-4568
US

IV. Provider business mailing address

260 HOSPITAL DR STE 204
UKIAH CA
95482-4568
US

V. Phone/Fax

Practice location:
  • Phone: 707-467-5220
  • Fax: 707-468-9179
Mailing address:
  • Phone: 707-467-5220
  • Fax: 707-468-9179

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number05-32303
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20A22842
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number22842
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: