Provider Demographics
NPI:1780274142
Name:SAMSON, MARK CASTILLO (DC)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:CASTILLO
Last Name:SAMSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1170 CONCORD AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94520-5652
Mailing Address - Country:US
Mailing Address - Phone:925-681-0801
Mailing Address - Fax:
Practice Address - Street 1:1170 CONCORD AVE STE 100
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94520-5652
Practice Address - Country:US
Practice Address - Phone:925-681-0801
Practice Address - Fax:925-681-0811
Is Sole Proprietor?:No
Enumeration Date:2021-01-20
Last Update Date:2021-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34786111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA34786OtherSTATE LICENSE