Provider Demographics
NPI:1245327840
Name:POMERANTZ, MARK FORD (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:FORD
Last Name:POMERANTZ
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 1:1400 E. CHURCH STREET
Mailing Address - Street 2:ATTENTION: MEDICAL STAFF OFFICE
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93454
Mailing Address - Country:US
Mailing Address - Phone:805-739-3954
Mailing Address - Fax:805-739-3060
Practice Address - Street 1:2271 S. DEPOT STREET
Practice Address - Street 2:
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93455
Practice Address - Country:US
Practice Address - Phone:805-922-0561
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2019-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG48284208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G482840OtherBLUE SHIELD
CA00G482840OtherBLUE SHIELD
A50994Medicare UPIN