Provider Demographics
NPI:1164409983
Name:HENDRICKS, MARK D (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:D
Last Name:HENDRICKS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:2525 CAMINO DEL RIO S STE 165
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-3742
Mailing Address - Country:US
Mailing Address - Phone:619-543-9655
Mailing Address - Fax:619-543-9658
Practice Address - Street 1:2525 CAMINO DEL RIO S STE 165
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-3742
Practice Address - Country:US
Practice Address - Phone:619-543-9655
Practice Address - Fax:619-543-9658
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-22
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG62541207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE93849Medicare UPIN