Provider Demographics
NPI:1972509016
Name:RUNFOLA, MARK ANTHONY (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ANTHONY
Last Name:RUNFOLA
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 1:2945 S DOBSON RD
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85202-7980
Mailing Address - Country:US
Mailing Address - Phone:480-969-4138
Mailing Address - Fax:480-969-0630
Practice Address - Street 1:2945 S DOBSON RD
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85202-7980
Practice Address - Country:US
Practice Address - Phone:480-969-4138
Practice Address - Fax:480-969-0630
Is Sole Proprietor?:No
Enumeration Date:2005-06-23
Last Update Date:2018-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ28152208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ536360Medicaid
H21818Medicare UPIN
AZ70100Medicare PIN