Provider Demographics
NPI:1659537264
Name:MARK T. FAHLEN, MD, INC. A PROFESSIONAL MEDICAL CORPORATION
Entity Type:Organization
Organization Name:MARK T. FAHLEN, MD, INC. A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:THEODORE
Authorized Official - Last Name:FAHLEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:209-544-2910
Mailing Address - Street 1:1400 FLORIDA AVE
Mailing Address - Street 2:SUITE 109
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-4422
Mailing Address - Country:US
Mailing Address - Phone:209-544-2910
Mailing Address - Fax:209-544-2253
Practice Address - Street 1:1400 FLORIDA AVE
Practice Address - Street 2:SUITE 109
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4422
Practice Address - Country:US
Practice Address - Phone:209-544-2910
Practice Address - Fax:209-544-2253
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-03
Last Update Date:2011-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA81212207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH85858Medicare UPIN