Provider Demographics
NPI:1396037537
Name:BOONYASAMPANT, MARK (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:BOONYASAMPANT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:101 E VALENCIA MESA DR
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92835-3809
Mailing Address - Country:US
Mailing Address - Phone:510-388-7271
Mailing Address - Fax:714-446-7546
Practice Address - Street 1:101 E VALENCIA MESA DR
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92835-3809
Practice Address - Country:US
Practice Address - Phone:510-388-7271
Practice Address - Fax:714-446-7546
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA126158207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology