Provider Demographics
NPI:1063633808
Name:ABO, MARK ALDWIN BERNARDINO (PT)
Entity Type:Individual
Prefix:MR
First Name:MARK ALDWIN
Middle Name:BERNARDINO
Last Name:ABO
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:20840 COMMUNITY ST UNIT 21
Mailing Address - Street 2:
Mailing Address - City:WINNETKA
Mailing Address - State:CA
Mailing Address - Zip Code:91306-1522
Mailing Address - Country:US
Mailing Address - Phone:818-458-0339
Mailing Address - Fax:
Practice Address - Street 1:20840 COMMUNITY ST UNIT 21
Practice Address - Street 2:
Practice Address - City:WINNETKA
Practice Address - State:CA
Practice Address - Zip Code:91306-1522
Practice Address - Country:US
Practice Address - Phone:818-458-0339
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT28714225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist