Provider Demographics
NPI:1407930209
Name:PARDOE, MARK B (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:B
Last Name:PARDOE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2752 HARRISON AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:EUREKA
Mailing Address - State:CA
Mailing Address - Zip Code:95501-4738
Mailing Address - Country:US
Mailing Address - Phone:707-445-3075
Mailing Address - Fax:707-445-3076
Practice Address - Street 1:2752 HARRISON AVE
Practice Address - Street 2:SUITE A
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95501-4738
Practice Address - Country:US
Practice Address - Phone:707-445-3075
Practice Address - Fax:707-445-3076
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2021-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA78580208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A785800Medicaid
CACH433ZMedicare PIN
CA00A785800Medicaid
CA00A785800Medicare PIN
CH433ZMedicare PIN