Provider Demographics
NPI:1295842292
Name:MARK R SAWUSCH MD INC
Entity Type:Organization
Organization Name:MARK R SAWUSCH MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:RAYMOND
Authorized Official - Last Name:SAWUSCH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-454-5521
Mailing Address - Street 1:970 MONUMENT ST #204
Mailing Address - Street 2:
Mailing Address - City:PACIFIC PALISADES
Mailing Address - State:CA
Mailing Address - Zip Code:90272
Mailing Address - Country:US
Mailing Address - Phone:310-454-5521
Mailing Address - Fax:310-454-1199
Practice Address - Street 1:970 MONUMENT ST #204
Practice Address - Street 2:
Practice Address - City:PACIFIC PALISADES
Practice Address - State:CA
Practice Address - Zip Code:90272
Practice Address - Country:US
Practice Address - Phone:310-454-5521
Practice Address - Fax:310-454-1199
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG65646207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G656461Medicaid
E57287Medicare UPIN
G65646Medicare ID - Type Unspecified