Provider Demographics
NPI:1013963594
Name:REDOR, MARK W (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:W
Last Name:REDOR
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 1:1006 MARSHALL WAY
Mailing Address - Street 2:
Mailing Address - City:PLACERVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95667-5706
Mailing Address - Country:US
Mailing Address - Phone:530-622-6430
Mailing Address - Fax:530-622-3957
Practice Address - Street 1:1006 MARSHALL WAY
Practice Address - Street 2:
Practice Address - City:PLACERVILLE
Practice Address - State:CA
Practice Address - Zip Code:95667-5706
Practice Address - Country:US
Practice Address - Phone:530-622-6430
Practice Address - Fax:530-622-3957
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-26
Last Update Date:2009-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG56411174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
F25981Medicare UPIN
00G564110Medicare PIN
CAF25981Medicare UPIN
CA00G564110Medicare ID - Type Unspecified