Provider Demographics
NPI:1801898929
Name:FREEMAN, MARK J (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:J
Last Name:FREEMAN
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Gender:M
Credentials:MD
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Mailing Address - Street 1:15322 LAKESHORE DR
Mailing Address - Street 2:STE 101
Mailing Address - City:CLEARLAKE
Mailing Address - State:CA
Mailing Address - Zip Code:95422-9815
Mailing Address - Country:US
Mailing Address - Phone:707-995-1362
Mailing Address - Fax:707-995-7057
Practice Address - Street 1:15322 LAKESHORE DR
Practice Address - Street 2:STE 101
Practice Address - City:CLEARLAKE
Practice Address - State:CA
Practice Address - Zip Code:95422-9815
Practice Address - Country:US
Practice Address - Phone:707-995-1362
Practice Address - Fax:707-995-7057
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-01
Last Update Date:2009-04-17
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Provider Licenses
StateLicense IDTaxonomies
CAG47688207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G476880Medicaid
CAP00660683OtherMEDICARE RAILROAD #
080150278OtherMEDICARE RAILROAD #
080150278OtherMEDICARE RAILROAD #
CAP00660683OtherMEDICARE RAILROAD #
CABF953ZMedicare PIN