Provider Demographics
NPI:1073743233
Name:IGNATIUS, MARK IVAN (DO)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:IVAN
Last Name:IGNATIUS
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 1:3838 CALIFORNIA ST RM 715
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94118-1509
Mailing Address - Country:US
Mailing Address - Phone:415-668-8010
Mailing Address - Fax:415-592-2560
Practice Address - Street 1:3838 CALIFORNIA ST RM 715
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94118-1509
Practice Address - Country:US
Practice Address - Phone:415-668-8010
Practice Address - Fax:415-592-2560
Is Sole Proprietor?:No
Enumeration Date:2009-07-22
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101018183208100000X
CA20A11498208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHJ557ZMedicare PIN