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General NPI Number Information
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NPI Number | 1245958453
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Entity Type | Individual
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Provider Name | MARK ANANTIYO
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Gender | Male
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Dates
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Enumeration Date | 08/15/2022
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Last Update Date | 05/01/2023
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Provider Practice Location Address
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Address Line | 309 E 2ND ST
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City | POMONA
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State | CA
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Zip | 91766-1854
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Country | US
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Telephone | 909-623-6111
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Fax |
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Provider Business Mailing Address
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Address Line | 7617 E HOLLOW OAK RD
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City | ANAHEIM
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State | CA
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Zip | 92808-1426
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | PA61663
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License Number State | CA
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