Basic Information
| Provider Information | |||||||||
| NPI: | 1033164793 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SAMBERG | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3400 DATA DR | ||||||||
| Address2: | QUALITY DEPT., 2ND FL | ||||||||
| City: | RANCHO CORDOVA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956707956 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9163792861 | ||||||||
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| Practice Location | |||||||||
| Address1: | 315 MERCY AVE | ||||||||
| Address2: | STE 400 | ||||||||
| City: | MERCED | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953408363 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2095643700 | ||||||||
| FaxNumber: | 2095643799 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2006 | ||||||||
| LastUpdateDate: | 09/21/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | G36285 | CA | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 00G362850 | 05 | CA | MEDICAID |