Provider Demographics
NPI:1831313378
Name:CARLISLE, MARK (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:CARLISLE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3000 COLBY ST
Mailing Address - Street 2:SUITE 205
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94705-2083
Mailing Address - Country:US
Mailing Address - Phone:510-666-0854
Mailing Address - Fax:
Practice Address - Street 1:3000 COLBY ST
Practice Address - Street 2:SUITE 205
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94705-2083
Practice Address - Country:US
Practice Address - Phone:510-666-0854
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-13
Last Update Date:2014-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA91492207L00000X, 207LP2900X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1831313378Medicaid