Provider Demographics
NPI:1790714160
Name:DE DUBOVAY, MARK (DC)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:DE DUBOVAY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14340 BOLSA CHICA RD STE G
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:CA
Mailing Address - Zip Code:92683-4868
Mailing Address - Country:US
Mailing Address - Phone:562-795-6680
Mailing Address - Fax:562-799-9575
Practice Address - Street 1:14340 BOLSA CHICA RD STE G
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:CA
Practice Address - Zip Code:92683
Practice Address - Country:US
Practice Address - Phone:562-795-6680
Practice Address - Fax:562-799-9575
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2018-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC17394111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0173940OtherBLUE SHIELD LICENSE NO.
CADC0173940OtherBLUE SHIELD LICENSE NO.
CAWDC17394AMedicare ID - Type UnspecifiedMEDICARE LICENSE NO.