Provider Demographics
NPI:1649506643
Name:PERRAULT, MARK D (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:D
Last Name:PERRAULT
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Gender:M
Credentials:MD
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Mailing Address - Street 1:3940 OLMSTED AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90008-2626
Mailing Address - Country:US
Mailing Address - Phone:323-736-0977
Mailing Address - Fax:310-733-1835
Practice Address - Street 1:11111 JEFFERSON BLVD
Practice Address - Street 2:5005
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90230-6903
Practice Address - Country:US
Practice Address - Phone:323-736-0977
Practice Address - Fax:310-733-1835
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-26
Last Update Date:2022-01-11
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Provider Licenses
StateLicense IDTaxonomies
CAA435502084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry