Provider Demographics
NPI:1043235815
Name:MAR, JEFFREY N (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:N
Last Name:MAR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9479 HAVEN AVE
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-5844
Mailing Address - Country:US
Mailing Address - Phone:909-771-8023
Mailing Address - Fax:909-989-0606
Practice Address - Street 1:9479 HAVEN AVE
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-5844
Practice Address - Country:US
Practice Address - Phone:909-771-8023
Practice Address - Fax:909-989-0606
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2012-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA873482084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A873480Medicaid
00A873480Medicare ID - Type Unspecified
I11476Medicare UPIN