Provider Demographics
NPI: | 1437154143 |
---|---|
Name: | BOISKIN, MARK M (MD) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | MARK |
Middle Name: | M |
Last Name: | BOISKIN |
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: | 4225 EXECUTIVE SQ STE 450 |
Mailing Address - Street 2: | |
Mailing Address - City: | LA JOLLA |
Mailing Address - State: | CA |
Mailing Address - Zip Code: | 92037-8411 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 858-810-0000 |
Mailing Address - Fax: | 858-268-1911 |
Practice Address - Street 1: | 9834 GENESEE AVE |
Practice Address - Street 2: | STE 312 |
Practice Address - City: | LA JOLLA |
Practice Address - State: | CA |
Practice Address - Zip Code: | 92037-1223 |
Practice Address - Country: | US |
Practice Address - Phone: | 858-558-8150 |
Practice Address - Fax: | 858-346-1024 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2005-06-17 |
Last Update Date: | 2021-02-02 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
CA | A52055 | 207RN0300X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207RN0300X | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
CA | 00A520550 | Other | BLUE SHIELD OF CA |
CA | 00A520550 | Medicaid | |
CA | AQ039X | Other | NO. CALIFORNIA PTAN |
CA | WA52055L | Other | SO. CALIFORNIA PTAN |
CA | AQ039X | Other | NO. CALIFORNIA PTAN |