Provider Demographics
NPI:1205425683
Name:NAVASCA, MARK BANTUGAN (MS, OTR/L)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:BANTUGAN
Last Name:NAVASCA
Suffix:
Gender:M
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1222 NESTWOOD WAY
Mailing Address - Street 2:
Mailing Address - City:MILPITAS
Mailing Address - State:CA
Mailing Address - Zip Code:95035-9004
Mailing Address - Country:US
Mailing Address - Phone:510-449-6425
Mailing Address - Fax:
Practice Address - Street 1:1975 TICE VALLEY BLVD
Practice Address - Street 2:
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94595-2201
Practice Address - Country:US
Practice Address - Phone:925-906-0200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-11
Last Update Date:2021-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12462225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist