Provider Demographics
NPI:1952607657
Name:MARK DRUCKER, D.P.M., A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:MARK DRUCKER, D.P.M., A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BOOKKEEPER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JUDY
Authorized Official - Middle Name:M
Authorized Official - Last Name:MILLIKIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:415-472-5575
Mailing Address - Street 1:750 LAS GALLINAS AVE
Mailing Address - Street 2:SUITE 115
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903-3438
Mailing Address - Country:US
Mailing Address - Phone:415-472-5575
Mailing Address - Fax:415-472-0502
Practice Address - Street 1:750 LAS GALLINAS AVE
Practice Address - Street 2:SUITE 115
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94903-3438
Practice Address - Country:US
Practice Address - Phone:415-472-5575
Practice Address - Fax:415-472-0502
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-28
Last Update Date:2011-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E15610Medicare PIN