Provider Demographics
NPI:1295180891
Name:POGGETTI, MARK JOHN (PT, DPT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:JOHN
Last Name:POGGETTI
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2121B JONES ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94133-7114
Mailing Address - Country:US
Mailing Address - Phone:415-710-1767
Mailing Address - Fax:
Practice Address - Street 1:619 E BLITHEDALE AVE
Practice Address - Street 2:
Practice Address - City:MILL VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94941-1482
Practice Address - Country:US
Practice Address - Phone:415-388-5223
Practice Address - Fax:415-388-5270
Is Sole Proprietor?:No
Enumeration Date:2016-05-02
Last Update Date:2016-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34144225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist