Basic Information
| Provider Information | |||||||||
| NPI: | 1497744247 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | O'BRIEN | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2604 EL CAMINO REAL | ||||||||
| Address2: | SUITE 392 | ||||||||
| City: | CARLSBAD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920081205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8772868459 | ||||||||
| FaxNumber: | 7604396581 | ||||||||
| Practice Location | |||||||||
| Address1: | 3156 VISTA WAY | ||||||||
| Address2: | SUITE 405 | ||||||||
| City: | OCEANSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920563622 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7604396581 | ||||||||
| FaxNumber: | 7607696585 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/14/2005 | ||||||||
| LastUpdateDate: | 12/13/2010 | ||||||||
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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 | 174400000X | 20A6017 | CA | Y | Other Service Providers | Specialist |
No ID Information.