Provider Demographics
NPI:1073249918
Name:MIKHAIL, MARK SAMEH (RADT)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:SAMEH
Last Name:MIKHAIL
Suffix:
Gender:M
Credentials:RADT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3145 IMPERIAL AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92102-4319
Mailing Address - Country:US
Mailing Address - Phone:909-296-2508
Mailing Address - Fax:
Practice Address - Street 1:3145 IMPERIAL AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92102-4319
Practice Address - Country:US
Practice Address - Phone:909-296-2508
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-25
Last Update Date:2022-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)