Provider Demographics
NPI:1073750097
Name:OSTERLOH, MARK DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:DAVID
Last Name:OSTERLOH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:DAVID
Other - Middle Name:MARK
Other - Last Name:OSTERLOH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:100 E CALIFORNIA BLVD
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91105
Mailing Address - Country:US
Mailing Address - Phone:626-568-8838
Mailing Address - Fax:626-583-8838
Practice Address - Street 1:1420 OCOTILLO DRIVE STE. D
Practice Address - Street 2:
Practice Address - City:EL CENTRO
Practice Address - State:CA
Practice Address - Zip Code:92243-4213
Practice Address - Country:US
Practice Address - Phone:541-343-5000
Practice Address - Fax:541-344-9478
Is Sole Proprietor?:No
Enumeration Date:2009-01-13
Last Update Date:2014-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ22712207W00000X
ORMD150106207W00000X
CAG57210207W00000X
OH35.048333207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology