Provider Demographics
NPI:1760615322
Name:MARK, ALEXANDRA (MS, RD)
Entity Type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:
Last Name:MARK
Suffix:
Gender:F
Credentials:MS, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:307 33RD ST
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92663-3131
Mailing Address - Country:US
Mailing Address - Phone:646-267-6314
Mailing Address - Fax:
Practice Address - Street 1:26800 CROWN VALLEY PKWY
Practice Address - Street 2:SUITE 230
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-6384
Practice Address - Country:US
Practice Address - Phone:949-542-8004
Practice Address - Fax:949-364-3682
Is Sole Proprietor?:No
Enumeration Date:2009-08-31
Last Update Date:2013-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADL492ZMedicare PIN
CADL492YMedicare PIN