Provider Demographics
NPI:1497744247
Name:O'BRIEN, MARK (DO)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:O'BRIEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2604 EL CAMINO REAL
Mailing Address - Street 2:SUITE 392
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92008-1205
Mailing Address - Country:US
Mailing Address - Phone:877-286-8459
Mailing Address - Fax:760-439-6581
Practice Address - Street 1:3156 VISTA WAY
Practice Address - Street 2:SUITE 405
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92056-3622
Practice Address - Country:US
Practice Address - Phone:760-439-6581
Practice Address - Fax:760-769-6585
Is Sole Proprietor?:No
Enumeration Date:2005-10-14
Last Update Date:2010-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A6017174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
W20A6017LMedicare ID - Type Unspecified
C84521Medicare UPIN