Provider Demographics
NPI:1710326749
Name:ILAGAN, MARK KHRYSTIAN (DO)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:KHRYSTIAN
Last Name:ILAGAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1717 E DATE PL
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92404-4428
Mailing Address - Country:US
Mailing Address - Phone:888-750-0036
Mailing Address - Fax:
Practice Address - Street 1:1717 E DATE PL
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404-4428
Practice Address - Country:US
Practice Address - Phone:888-750-0036
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-24
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A14538207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine