Provider Demographics
NPI:1083645360
Name:SCHAMBLIN, MARK L (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:L
Last Name:SCHAMBLIN
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 1:6815 NOBLE AVE
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91405-3796
Mailing Address - Country:US
Mailing Address - Phone:818-901-6600
Mailing Address - Fax:818-997-7826
Practice Address - Street 1:6815 NOBLE AVE
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91405-3796
Practice Address - Country:US
Practice Address - Phone:818-901-6600
Practice Address - Fax:818-997-7826
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2011-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA70815207X00000X, 207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP00249615OtherRRMCR
CAH91822Medicare UPIN
CA00A708150Medicare PIN