Provider Demographics
NPI:1639157282
Name:SADA, MARK J (MD, FACC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:J
Last Name:SADA
Suffix:
Gender:M
Credentials:MD, FACC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1941 JOHNSON AVE
Mailing Address - Street 2:STE 101
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-4154
Mailing Address - Country:US
Mailing Address - Phone:805-782-8844
Mailing Address - Fax:805-782-8859
Practice Address - Street 1:1941 JOHNSON AVE
Practice Address - Street 2:STE 101
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-4154
Practice Address - Country:US
Practice Address - Phone:805-782-8844
Practice Address - Fax:805-782-8859
Is Sole Proprietor?:No
Enumeration Date:2006-01-04
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG69997207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G699970Medicaid
CAZZZ28458ZOtherBLUE SHIELD
CA990003291OtherRR MEDI-CARE
WG69997NMedicare PIN
CA00G699970Medicaid
CAWG69997OMedicare PIN
CAZZZ28458ZOtherBLUE SHIELD
CAWG69997MMedicare PIN
CAWG69997LMedicare PIN
CAWG69997OMedicare PIN
CAF11903Medicare UPIN
CAWG69997HMedicare PIN