Provider Demographics
NPI:1619959079
Name:CONDELL, MARK GUY (OD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:GUY
Last Name:CONDELL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27201 REGIO
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92692-3206
Mailing Address - Country:US
Mailing Address - Phone:949-701-2576
Mailing Address - Fax:
Practice Address - Street 1:27201 REGIO
Practice Address - Street 2:
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92692-3206
Practice Address - Country:US
Practice Address - Phone:949-701-2576
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-18
Last Update Date:2019-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT7778T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD007778Medicaid
T70225Medicare UPIN