Provider Demographics
NPI:1003831041
Name:TAPSCOTT, MARK ALLEN (DO)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ALLEN
Last Name:TAPSCOTT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5555 RESERVOIR DR
Mailing Address - Street 2:SUITE 203
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92120-5134
Mailing Address - Country:US
Mailing Address - Phone:619-287-2590
Mailing Address - Fax:619-287-2913
Practice Address - Street 1:5555 RESERVOIR DR
Practice Address - Street 2:SUITE 203
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92120-5134
Practice Address - Country:US
Practice Address - Phone:619-287-2590
Practice Address - Fax:619-287-2913
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2009-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A5472174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX54720Medicaid
CA00AX54720Medicaid
CA20A5472Medicare ID - Type Unspecified