Provider Demographics
NPI:1013961275
Name:MAKO, MARK (PT, OCS)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:MAKO
Suffix:
Gender:M
Credentials:PT, OCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2585 COCHRAN ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93065-2602
Mailing Address - Country:US
Mailing Address - Phone:805-584-0001
Mailing Address - Fax:805-527-9135
Practice Address - Street 1:2585 COCHRAN ST
Practice Address - Street 2:SUITE A
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93065-2602
Practice Address - Country:US
Practice Address - Phone:805-584-0001
Practice Address - Fax:805-527-9135
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2007-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 15347225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA77057605493065A002OtherTRICARE
CAPT00015347OtherBLUE CROSS OF CA
CA0PT153470OtherBLUE SHIELD OF CA
CAPT00015347OtherBLUE CROSS OF CA
CA0PT153470OtherBLUE SHIELD OF CA