Provider Demographics
NPI:1295027613
Name:MARK VENTOCILLA, O.D., INC
Entity Type:Organization
Organization Name:MARK VENTOCILLA, O.D., INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:AUGUSTO
Authorized Official - Last Name:VENTOCILLA
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:616-502-0069
Mailing Address - Street 1:613 E GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92025-4402
Mailing Address - Country:US
Mailing Address - Phone:760-747-7979
Mailing Address - Fax:760-747-7799
Practice Address - Street 1:613 E GRAND AVE
Practice Address - Street 2:
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92025-4402
Practice Address - Country:US
Practice Address - Phone:760-747-7979
Practice Address - Fax:760-747-7799
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-03
Last Update Date:2012-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10435152WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WP0200XEye and Vision Services ProvidersOptometristPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFD584AMedicare PIN