Provider Demographics
NPI:1245084458
Name:DOMINGO, MARK RYAN VENTURA
Entity type:Individual
Prefix:
First Name:MARK RYAN
Middle Name:VENTURA
Last Name:DOMINGO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 SKLAR ST APT 603
Mailing Address - Street 2:
Mailing Address - City:LADERA RANCH
Mailing Address - State:CA
Mailing Address - Zip Code:92694-0766
Mailing Address - Country:US
Mailing Address - Phone:949-615-8407
Mailing Address - Fax:
Practice Address - Street 1:33608 ORTEGA HWY SAN JUAN CAPISTRANO
Practice Address - Street 2:
Practice Address - City:SAN JUAN CAPISTRANO
Practice Address - State:CA
Practice Address - Zip Code:92675
Practice Address - Country:US
Practice Address - Phone:800-642-4657
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-15
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMTA-02245121246QM0706X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246QM0706XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, PathologyMedical Technologist