Provider Demographics
NPI:1801969829
Name:ROBACK, MARK TODD (DO)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:TODD
Last Name:ROBACK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:670 9TH STREET
Mailing Address - Street 2:SUITE 203
Mailing Address - City:ARCATA
Mailing Address - State:CA
Mailing Address - Zip Code:95521-6249
Mailing Address - Country:US
Mailing Address - Phone:707-826-8633
Mailing Address - Fax:707-826-8638
Practice Address - Street 1:3304 RENNER DR
Practice Address - Street 2:
Practice Address - City:FORTUNA
Practice Address - State:CA
Practice Address - Zip Code:95540-7102
Practice Address - Country:US
Practice Address - Phone:707-725-4477
Practice Address - Fax:707-725-9209
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2014-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYR1153207Q00000X
CA20A10324208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100028230Medicaid
KYR1153OtherTEMP LICENSE
CA1801969829OtherNPI
0683240Medicare PIN
0601443Medicare PIN
KY7100028230Medicaid
0903682Medicare PIN
KYP00404552Medicare PIN
KYR1153OtherTEMP LICENSE
CA172347Medicare UPIN
CA1801969829OtherNPI
0952012Medicare PIN
0745827Medicare PIN
0935388Medicare PIN
0396858Medicare PIN