Provider Demographics
NPI:1447200498
Name:BASKIN, MARK ALAN (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ALAN
Last Name:BASKIN
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 1:16550 VENTURA BLVD
Mailing Address - Street 2:SUITE 406
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-5028
Mailing Address - Country:US
Mailing Address - Phone:818-905-5115
Mailing Address - Fax:
Practice Address - Street 1:16550 VENTURA BLVD
Practice Address - Street 2:SUITE 406
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-5028
Practice Address - Country:US
Practice Address - Phone:818-905-5115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-11
Last Update Date:2008-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG30252207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG30252BMedicare PIN