Provider Demographics
NPI:1508251836
Name:MAYOL, MARK DARNOLD CAGAMPANG
Entity Type:Individual
Prefix:
First Name:MARK DARNOLD
Middle Name:CAGAMPANG
Last Name:MAYOL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1724 E WOODBURY RD
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91104-1539
Mailing Address - Country:US
Mailing Address - Phone:626-298-0603
Mailing Address - Fax:
Practice Address - Street 1:63 S PARKWOOD AVE
Practice Address - Street 2:APT 4
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91107-3538
Practice Address - Country:US
Practice Address - Phone:626-298-0603
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-02
Last Update Date:2015-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY037670225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist