Provider Demographics
NPI:1356364707
Name:HADDAD, MARK DALLAS (MA DISPENSER AUDIOP)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:DALLAS
Last Name:HADDAD
Suffix:
Gender:M
Credentials:MA DISPENSER AUDIOP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6539
Mailing Address - Street 2:
Mailing Address - City:BUENA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90622
Mailing Address - Country:US
Mailing Address - Phone:714-229-9178
Mailing Address - Fax:714-229-9187
Practice Address - Street 1:6888 LINCOLN AVE
Practice Address - Street 2:SUITE E & H
Practice Address - City:BUENA PARK
Practice Address - State:CA
Practice Address - Zip Code:90620
Practice Address - Country:US
Practice Address - Phone:714-229-9178
Practice Address - Fax:714-229-9187
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2008-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAHA3988237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHA0039880Medicaid