Provider Demographics
NPI:1891854568
Name:SONTAG, MARK JORDAN (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:JORDAN
Last Name:SONTAG
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:363 MAIN ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:REDWOOD CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94063-1729
Mailing Address - Country:US
Mailing Address - Phone:650-306-9490
Mailing Address - Fax:650-306-0250
Practice Address - Street 1:363 MAIN ST
Practice Address - Street 2:SUITE C
Practice Address - City:REDWOOD CITY
Practice Address - State:CA
Practice Address - Zip Code:94063-1729
Practice Address - Country:US
Practice Address - Phone:650-306-9490
Practice Address - Fax:650-306-0250
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-08
Last Update Date:2009-05-28
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAG052976208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ37287ZMedicare PIN
A52404Medicare UPIN
CAZZZ37287ZMedicare ID - Type Unspecified