Provider Demographics
NPI:1639239528
Name:MARK J SONTAG MD
Entity Type:Organization
Organization Name:MARK J SONTAG MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:JORDAN
Authorized Official - Last Name:SONTAG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:650-306-9490
Mailing Address - Street 1:363 MAIN ST
Mailing Address - Street 2:C
Mailing Address - City:REDWOOD CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94063-1729
Mailing Address - Country:US
Mailing Address - Phone:650-306-9490
Mailing Address - Fax:650-306-0250
Practice Address - Street 1:363 MAIN STREET
Practice Address - Street 2:C
Practice Address - City:REDWOOD CITY
Practice Address - State:CA
Practice Address - Zip Code:94063
Practice Address - Country:US
Practice Address - Phone:650-306-9490
Practice Address - Fax:650-306-0250
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2008-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ37287ZMedicare PIN