Provider Demographics
NPI:1235373549
Name:ESCUDERO, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:ESCUDERO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:938 OLD RANCH HOUSE RD
Mailing Address - Street 2:
Mailing Address - City:ROCKLIN
Mailing Address - State:CA
Mailing Address - Zip Code:95765-6285
Mailing Address - Country:US
Mailing Address - Phone:858-337-6226
Mailing Address - Fax:
Practice Address - Street 1:1600 EUREKA RD
Practice Address - Street 2:DEPT OF RADIOLOGY
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-3027
Practice Address - Country:US
Practice Address - Phone:858-337-6226
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-30
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA1296332085P0229X, 2085P0229X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric Radiology