Provider Demographics
NPI:1750418489
Name:DE MARIA, MARK STEVEN (PT)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:STEVEN
Last Name:DE MARIA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1412 GRAND ST
Mailing Address - Street 2:
Mailing Address - City:ALAMEDA
Mailing Address - State:CA
Mailing Address - Zip Code:94501-2507
Mailing Address - Country:US
Mailing Address - Phone:510-337-0283
Mailing Address - Fax:510-337-0521
Practice Address - Street 1:1412 GRAND ST
Practice Address - Street 2:
Practice Address - City:ALAMEDA
Practice Address - State:CA
Practice Address - Zip Code:94501-2507
Practice Address - Country:US
Practice Address - Phone:510-337-0283
Practice Address - Fax:510-337-0521
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT19001225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0PT190011Medicare ID - Type Unspecified