Provider Demographics
NPI:1720013550
Name:DRUCKER, MARK (DPM)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:DRUCKER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:750 LAS GALLINAS AVE
Mailing Address - Street 2:SUITE 115
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903-3438
Mailing Address - Country:US
Mailing Address - Phone:415-472-5575
Mailing Address - Fax:415-472-0502
Practice Address - Street 1:750 LAS GALLINAS AVE
Practice Address - Street 2:SUITE 115
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94903-3438
Practice Address - Country:US
Practice Address - Phone:415-472-5575
Practice Address - Fax:415-472-0502
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2011-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE1561213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE1561OtherLICENSE #
CA94-2682725OtherTAX ID #
CA94-2682725OtherTAX ID #
CA000E15610Medicare PIN