Provider Demographics
NPI:1619974409
Name:FREITAG, MARK C (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:C
Last Name:FREITAG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:67555 E PALM CANYON DR STE C112
Mailing Address - Street 2:
Mailing Address - City:CATHEDRAL CITY
Mailing Address - State:CA
Mailing Address - Zip Code:92234-5412
Mailing Address - Country:US
Mailing Address - Phone:760-773-1680
Mailing Address - Fax:760-328-9379
Practice Address - Street 1:67780 E. PALM CANYON DRIVE
Practice Address - Street 2:SUITE 100
Practice Address - City:CATHEDRAL CITY
Practice Address - State:CA
Practice Address - Zip Code:92234
Practice Address - Country:US
Practice Address - Phone:760-773-1680
Practice Address - Fax:760-328-9379
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2018-08-09
Deactivation Date:2006-03-20
Deactivation Code:
Reactivation Date:2006-03-28
Provider Licenses
StateLicense IDTaxonomies
CAA45860207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF19354Medicare UPIN
CA00A458600Medicare ID - Type Unspecified