Provider Demographics
NPI:1003841248
Name:SUTTON, MARK S (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:S
Last Name:SUTTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:930 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BARSTOW
Mailing Address - State:CA
Mailing Address - Zip Code:92311-2654
Mailing Address - Country:US
Mailing Address - Phone:760-256-1004
Mailing Address - Fax:760-256-1055
Practice Address - Street 1:121 S 7TH AVE STE A
Practice Address - Street 2:
Practice Address - City:BARSTOW
Practice Address - State:CA
Practice Address - Zip Code:92311-3059
Practice Address - Country:US
Practice Address - Phone:760-818-4228
Practice Address - Fax:760-256-1055
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2024-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG27354207N00000X
CAG72354207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G723540Medicaid
CA00G723540Medicaid
00G723542Medicare ID - Type Unspecified