Provider Demographics
NPI:1710971502
Name:MARK, KELVIN C (DO)
Entity Type:Individual
Prefix:DR
First Name:KELVIN
Middle Name:C
Last Name:MARK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 660910
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95866-0910
Mailing Address - Country:US
Mailing Address - Phone:916-481-6800
Mailing Address - Fax:916-481-1881
Practice Address - Street 1:3315 WATT AVE
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95821-3600
Practice Address - Country:US
Practice Address - Phone:916-481-6800
Practice Address - Fax:916-481-1881
Is Sole Proprietor?:No
Enumeration Date:2005-09-07
Last Update Date:2010-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A6085207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0028370Medicaid
CAGR0028370Medicaid
CAZZZ16448ZMedicare ID - Type Unspecified