Provider Demographics
NPI:1043335607
Name:DEJONG, MARK (PT)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:DEJONG
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:220 STANDIFORD AVE
Mailing Address - Street 2:STE F
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-1159
Mailing Address - Country:US
Mailing Address - Phone:209-579-5628
Mailing Address - Fax:209-579-5637
Practice Address - Street 1:1041 N MAIN ST STE A
Practice Address - Street 2:
Practice Address - City:MANTECA
Practice Address - State:CA
Practice Address - Zip Code:95336-3988
Practice Address - Country:US
Practice Address - Phone:209-824-9888
Practice Address - Fax:209-824-9469
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2020-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT33493225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0PT 334930Medicare PIN