Provider Demographics
NPI:1447743182
Name:MARK D GAON MD INC
Entity Type:Organization
Organization Name:MARK D GAON MD INC
Other - Org Name:MARK D GAON MD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLER
Authorized Official - Prefix:
Authorized Official - First Name:ELSA
Authorized Official - Middle Name:
Authorized Official - Last Name:MUNGUIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-335-5461
Mailing Address - Street 1:10694 MAGNOLIA AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92505-1816
Mailing Address - Country:US
Mailing Address - Phone:951-335-5461
Mailing Address - Fax:951-335-5468
Practice Address - Street 1:1501 SUPERIOR AVE STE 300
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-3641
Practice Address - Country:US
Practice Address - Phone:949-642-3420
Practice Address - Fax:951-599-4664
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-07
Last Update Date:2023-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA872372086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty