Provider Demographics
NPI:1336832013
Name:GEORGE, ANTHONY MARK
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:MARK
Last Name:GEORGE
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 1:1255 KENDALL RD
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-8750
Mailing Address - Country:US
Mailing Address - Phone:805-441-2924
Mailing Address - Fax:
Practice Address - Street 1:1255 KENDALL RD
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-8750
Practice Address - Country:US
Practice Address - Phone:805-441-2924
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-30
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
175T00000X
CAMPSS-NWIHMG175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist