Provider Demographics
NPI:1245320704
Name:POPOVICH, MARK J (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:J
Last Name:POPOVICH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:325 DISTEL CIR
Mailing Address - Street 2:
Mailing Address - City:LOS ALTOS
Mailing Address - State:CA
Mailing Address - Zip Code:94022-1408
Mailing Address - Country:US
Mailing Address - Phone:707-521-4480
Mailing Address - Fax:707-521-4460
Practice Address - Street 1:3883 AIRWAY DR STE 100
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-1672
Practice Address - Country:US
Practice Address - Phone:707-521-4480
Practice Address - Fax:707-521-4460
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2019-08-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG579952085B0100X, 2085N0904X, 2085U0001X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
No2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear Radiology
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G579950Medicaid
CA473423OtherAMERICAN BOARD OF RADIOLOGY
CAG57995OtherSTATE MEDICAL LICENSE