Provider Demographics
NPI:1245958453
Name:ANANTIYO, MARK
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:ANANTIYO
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 1:7617 E HOLLOW OAK RD
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92808-1426
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:309 E 2ND ST
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91766-1854
Practice Address - Country:US
Practice Address - Phone:909-623-6111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-15
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
CAPA616632084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant