Provider Demographics
NPI:1639110257
Name:WARD, MARK ALAN (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ALAN
Last Name:WARD
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 1:355 LAS VEGAS ST
Mailing Address - Street 2:
Mailing Address - City:MORRO BAY
Mailing Address - State:CA
Mailing Address - Zip Code:93442-1548
Mailing Address - Country:US
Mailing Address - Phone:805-772-7100
Mailing Address - Fax:805-772-7776
Practice Address - Street 1:355 LAS VEGAS ST
Practice Address - Street 2:
Practice Address - City:MORRO BAY
Practice Address - State:CA
Practice Address - Zip Code:93442-1548
Practice Address - Country:US
Practice Address - Phone:805-772-7100
Practice Address - Fax:805-772-7776
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-08
Last Update Date:2014-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA83686207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A836860OtherBLUE SHIELD
CA00A836860Medicaid
CAA83686Medicare ID - Type Unspecified
CA00A836860OtherBLUE SHIELD
H95760Medicare UPIN