Provider Demographics
NPI:1497857999
Name:LESSNER, MARK M (MD)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:M
Last Name:LESSNER
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 1:1079 EUCALYPTUS ST, SUITE#A
Mailing Address - Street 2:
Mailing Address - City:MANTECA
Mailing Address - State:CA
Mailing Address - Zip Code:95337
Mailing Address - Country:US
Mailing Address - Phone:209-239-6008
Mailing Address - Fax:209-239-3408
Practice Address - Street 1:601 W RIVERSIDE DR STE 2
Practice Address - Street 2:
Practice Address - City:PARKER
Practice Address - State:AZ
Practice Address - Zip Code:85344-5119
Practice Address - Country:US
Practice Address - Phone:928-256-4110
Practice Address - Fax:928-722-6113
Is Sole Proprietor?:No
Enumeration Date:2006-09-04
Last Update Date:2021-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG33868207Q00000X
CA33868208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ594551Medicaid
CAC46470Medicare UPIN