Provider Demographics
NPI:1891806014
Name:BAZALGETTE, MARK BURRELL (MD)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:BURRELL
Last Name:BAZALGETTE
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 1:5 BON AIR RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LARKSPUR
Mailing Address - State:CA
Mailing Address - Zip Code:94939-1143
Mailing Address - Country:US
Mailing Address - Phone:415-924-2515
Mailing Address - Fax:415-924-2661
Practice Address - Street 1:165 ROWLAND WAY STE 200
Practice Address - Street 2:
Practice Address - City:NOVATO
Practice Address - State:CA
Practice Address - Zip Code:94945-5055
Practice Address - Country:US
Practice Address - Phone:415-827-0344
Practice Address - Fax:415-924-2661
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA46290208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A462900Medicaid
CA00A462900Medicaid
00A462900Medicare ID - Type Unspecified