Provider Demographics
NPI:1710412168
Name:JULIAN, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:JULIAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5450 NE 160TH AVE
Mailing Address - Street 2:
Mailing Address - City:WILLISTON
Mailing Address - State:FL
Mailing Address - Zip Code:32696-6434
Mailing Address - Country:US
Mailing Address - Phone:352-812-4376
Mailing Address - Fax:
Practice Address - Street 1:1117 E DEVONSHIRE AVE
Practice Address - Street 2:
Practice Address - City:HEMET
Practice Address - State:CA
Practice Address - Zip Code:92543-3083
Practice Address - Country:US
Practice Address - Phone:951-652-2811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-24
Last Update Date:2017-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
355543OtherAOA ID
13456209OtherAAMC ID