Provider Demographics
NPI:1265478564
Name:STEIN, MARK GEOFFERY (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:GEOFFERY
Last Name:STEIN
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 1:1100 N TUSTIN AVE
Mailing Address - Street 2:BLDG. A
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-3509
Mailing Address - Country:US
Mailing Address - Phone:714-835-6055
Mailing Address - Fax:714-285-9084
Practice Address - Street 1:1100 N TUSTIN AVE
Practice Address - Street 2:BLDG. A
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-3509
Practice Address - Country:US
Practice Address - Phone:714-835-6055
Practice Address - Fax:714-285-9084
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2015-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA388052085B0100X, 2085R0202X, 2085U0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A388050Medicaid
CAWA38805CMedicare PIN
E25279Medicare UPIN