Provider Demographics
NPI:1679539415
Name:FAHLEN, MARK T (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:T
Last Name:FAHLEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
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:
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:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-21
Last Update Date:2011-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA81212207R00000X, 207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH85858Medicare UPIN