Provider Demographics
NPI:1609051572
Name:MARK R NORTHFIELD, M.D.
Entity Type:Organization
Organization Name:MARK R NORTHFIELD, M.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RECEPTIONIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:LEE
Authorized Official - Middle Name:D
Authorized Official - Last Name:BRILL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-778-1131
Mailing Address - Street 1:1496 PROFESSIONAL DR
Mailing Address - Street 2:SUITE 601
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94954-6698
Mailing Address - Country:US
Mailing Address - Phone:707-778-1131
Mailing Address - Fax:707-778-3818
Practice Address - Street 1:1496 PROFESSIONAL DR
Practice Address - Street 2:SUITE 601
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94954-6698
Practice Address - Country:US
Practice Address - Phone:707-778-1131
Practice Address - Fax:707-778-3818
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-09
Last Update Date:2008-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG77114174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G77114Medicare PIN
CA1302010001Medicare NSC
CAF70479Medicare UPIN