Provider Demographics
NPI:1932329265
Name:JANZEN, MARK LAVERNE (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:LAVERNE
Last Name:JANZEN
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 1:10800 MAGNOLIA AVENUE, MOB1, 2ND FLOOR, MODULE 216
Mailing Address - Street 2:KAISER PERMANENTE RIVERSIDE MEDICAL CENTER
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92505
Mailing Address - Country:US
Mailing Address - Phone:440-781-0931
Mailing Address - Fax:
Practice Address - Street 1:10800 MAGNOLIA AVENUE,
Practice Address - Street 2:KAISER PERMANENTE RIVERSIDE MEDICAL CENTER
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92505
Practice Address - Country:US
Practice Address - Phone:440-781-0931
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-27
Last Update Date:2017-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH089484208600000X, 2086S0127X
CAA902032086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO152360469Medicare PIN