Provider Demographics
NPI:1093731937
Name:VANHOUTEN, MARK (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:VANHOUTEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:14150 CULVER DR
Mailing Address - Street 2:SUITE 307
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92604-0315
Mailing Address - Country:US
Mailing Address - Phone:949-548-4111
Mailing Address - Fax:949-548-9664
Practice Address - Street 1:14150 CULVER DR
Practice Address - Street 2:SUITE 307
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92604-0315
Practice Address - Country:US
Practice Address - Phone:949-548-4111
Practice Address - Fax:949-548-9664
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2014-06-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG562322084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWG56232PMedicare PIN
CAE90770Medicare UPIN