Provider Demographics
NPI:1265476493
Name:SIMONIAN, MARK MARTIN (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:MARTIN
Last Name:SIMONIAN
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 1:681 MEDICAL CENTER DR W
Mailing Address - Street 2:106
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93611-6803
Mailing Address - Country:US
Mailing Address - Phone:559-325-6850
Mailing Address - Fax:
Practice Address - Street 1:681 MEDICAL CENTER DR W
Practice Address - Street 2:106
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93611-6803
Practice Address - Country:US
Practice Address - Phone:559-325-6850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2009-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA32554208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA26-4031266OtherIRS S-CORP