Provider Demographics
NPI:1013960202
Name:BARAD, MARK GORDON (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:GORDON
Last Name:BARAD
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1554 S SEPULVEDA BLVD
Mailing Address - Street 2:SUITE 215
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-3377
Mailing Address - Country:US
Mailing Address - Phone:310-849-9055
Mailing Address - Fax:310-919-3666
Practice Address - Street 1:1554 S SEPULVEDA BLVD
Practice Address - Street 2:SUITE 215
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-3377
Practice Address - Country:US
Practice Address - Phone:310-849-9055
Practice Address - Fax:310-919-3666
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-18
Last Update Date:2015-05-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG853832084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G853830Medicaid
CAWG85383AMedicare ID - Type UnspecifiedUCLA