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General NPI Number Information
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NPI Number | 1659537264
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Entity Type | Organization
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Legal Business Name | MARK T. FAHLEN, MD, INC. A PROFESSIONAL MEDICAL CORPORATION
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Dates
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Enumeration Date | 08/03/2008
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Last Update Date | 08/02/2011
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Provider Practice Location Address
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Address Line | 1400 FLORIDA AVE SUITE 109
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City | MODESTO
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State | CA
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Zip | 95350-4422
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Country | US
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Telephone | 209-544-2910
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Fax | 209-544-2253
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Provider Business Mailing Address
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Address Line | 1400 FLORIDA AVE SUITE 109
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City | MODESTO
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State | CA
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Zip | 95350-4422
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Country | US
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Telephone | 209-544-2910
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Fax | 209-544-2253
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. MARK THEODORE FAHLEN
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Credential | M.D.
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Telephone | 209-544-2910
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RN0300X
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Taxonomy Name | Nephrology Physician
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License Number | A81212
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License Number State | CA
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