Provider Demographics
NPI:1851491989
Name:DWIGHT, MARK (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:DWIGHT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:637 LUCAS AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90017-1912
Mailing Address - Country:US
Mailing Address - Phone:213-977-4190
Mailing Address - Fax:213-250-4847
Practice Address - Street 1:637 LUCAS AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90017-1912
Practice Address - Country:US
Practice Address - Phone:213-977-4190
Practice Address - Fax:213-250-4847
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG66193207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF11385Medicare UPIN