Provider Demographics
NPI:1558676569
Name:MARK LOLLAR, M.D. INC
Entity Type:Organization
Organization Name:MARK LOLLAR, M.D. INC
Other - Org Name:MARK LOLLAR, M.D.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:WILLIAM LEE
Authorized Official - Last Name:LOLLAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:925-327-1500
Mailing Address - Street 1:5201 NORRIS CANYON RD STE 310
Mailing Address - Street 2:
Mailing Address - City:SAN RAMON
Mailing Address - State:CA
Mailing Address - Zip Code:94583-5405
Mailing Address - Country:US
Mailing Address - Phone:925-327-1500
Mailing Address - Fax:925-327-1900
Practice Address - Street 1:5201 NORRIS CANYON RD STE 310
Practice Address - Street 2:
Practice Address - City:SAN RAMON
Practice Address - State:CA
Practice Address - Zip Code:94583-5405
Practice Address - Country:US
Practice Address - Phone:925-327-1500
Practice Address - Fax:925-327-1900
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-13
Last Update Date:2010-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA50219174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF49986Medicare UPIN
CA00A502190Medicare PIN