Healthcare Provider Details

I. General information

NPI: 1477033678
Provider Name (Legal Business Name): MARK ANTHONY ATILANO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2018
Last Update Date: 12/14/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12461 BALSAM RD
VICTORVILLE CA
92395-9474
US

IV. Provider business mailing address

12461 BALSAM RD
VICTORVILLE CA
92395-9474
US

V. Phone/Fax

Practice location:
  • Phone: 760-792-2860
  • Fax:
Mailing address:
  • Phone: 760-792-2860
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: