Provider Demographics
NPI:1619063575
Name:ANTHONY, MARK (DC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:ANTHONY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15520 ROCKFIELD BLVD
Mailing Address - Street 2:STE A200
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92618-6705
Mailing Address - Country:US
Mailing Address - Phone:949-598-9999
Mailing Address - Fax:949-598-9990
Practice Address - Street 1:3935 FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:LA CRESCENTA
Practice Address - State:CA
Practice Address - Zip Code:91214-1621
Practice Address - Country:US
Practice Address - Phone:818-957-7035
Practice Address - Fax:818-957-7017
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2020-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC13928111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0139280OtherBLUE SHIELD
CAT17644Medicare UPIN
CADC13928Medicare ID - Type Unspecified