Provider Demographics
NPI:1568417152
Name:CHEN, MARK T (DO)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:T
Last Name:CHEN
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:PO BOX 1628
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92856-0628
Mailing Address - Country:US
Mailing Address - Phone:714-560-1580
Mailing Address - Fax:
Practice Address - Street 1:999 SAN BERNARDINO RD
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-4920
Practice Address - Country:US
Practice Address - Phone:909-920-4851
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2020-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A5641207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1106921Medicaid
WA8859351Medicare ID - Type Unspecified
WA1106921Medicaid