Provider Demographics
NPI:1225275076
Name:KINGSBURY, MARK BLAINE (DC)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:BLAINE
Last Name:KINGSBURY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:409 ALBERTO WAY
Mailing Address - Street 2:#3
Mailing Address - City:LOS GATOS
Mailing Address - State:CA
Mailing Address - Zip Code:95032-5407
Mailing Address - Country:US
Mailing Address - Phone:408-356-9459
Mailing Address - Fax:
Practice Address - Street 1:409 ALBERTO WAY
Practice Address - Street 2:#3
Practice Address - City:LOS GATOS
Practice Address - State:CA
Practice Address - Zip Code:95032-5407
Practice Address - Country:US
Practice Address - Phone:408-356-9459
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-15
Last Update Date:2010-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC28108111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0281080Medicare PIN