Provider Demographics
NPI:1336198449
Name:HOMICZ, MARK R (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:R
Last Name:HOMICZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:3536 MENDOCINO AVE
Mailing Address - Street 2:STE 200
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-3634
Mailing Address - Country:US
Mailing Address - Phone:707-575-6049
Mailing Address - Fax:707-523-3024
Practice Address - Street 1:1701 4TH ST STE 120
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-3661
Practice Address - Country:US
Practice Address - Phone:707-523-7025
Practice Address - Fax:707-523-3024
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2012-02-07
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAA70413207Y00000X, 207YX0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No207YX0007XAllopathic & Osteopathic PhysiciansOtolaryngologyPlastic Surgery within the Head & Neck
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A704130OtherBLUE SHIELD OF CALIFORNIA
CAP00933198OtherRAILROAD MEDICARE
I14720Medicare UPIN
CAEU981ZMedicare PIN
CA00A704130OtherBLUE SHIELD OF CALIFORNIA
CAP00933198OtherRAILROAD MEDICARE