Provider Demographics
NPI:1376736942
Name:YAMAKA, MARK STEVEN (CP)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:STEVEN
Last Name:YAMAKA
Suffix:
Gender:M
Credentials:CP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5940 E WASHINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:COMMERCE
Mailing Address - State:CA
Mailing Address - Zip Code:90040-2413
Mailing Address - Country:US
Mailing Address - Phone:323-721-6706
Mailing Address - Fax:323-721-6746
Practice Address - Street 1:5940 E WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:COMMERCE
Practice Address - State:CA
Practice Address - Zip Code:90040-2413
Practice Address - Country:US
Practice Address - Phone:323-721-6706
Practice Address - Fax:323-721-6746
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-27
Last Update Date:2007-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACP001339225000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAXB0013390Medicaid