Provider Demographics
NPI:1396436267
Name:RUIZ, MARK ERICSON
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:ERICSON
Last Name:RUIZ
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 1:2689 PRESIDIO DR
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:94513-5609
Mailing Address - Country:US
Mailing Address - Phone:925-698-1207
Mailing Address - Fax:925-392-8589
Practice Address - Street 1:2689 PRESIDIO DR
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:CA
Practice Address - Zip Code:94513-5609
Practice Address - Country:US
Practice Address - Phone:925-698-1207
Practice Address - Fax:925-392-8589
Is Sole Proprietor?:No
Enumeration Date:2023-05-19
Last Update Date:2023-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE1378718172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver