Provider Demographics
NPI:1104267145
Name:WAHRENBROCK, MARK GEOFFREY (MD, PHD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:GEOFFREY
Last Name:WAHRENBROCK
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8901 ACTIVITY RD STE 205
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92126-4436
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8901 ACTIVITY RD STE 205
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92126-4436
Practice Address - Country:US
Practice Address - Phone:888-992-7555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-06
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA158210207ZC0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZC0006XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology