Provider Demographics
NPI:1104991090
Name:TALAVERA, MARK G (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:G
Last Name:TALAVERA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1088
Mailing Address - Street 2:
Mailing Address - City:ARTESIA
Mailing Address - State:CA
Mailing Address - Zip Code:90702-1088
Mailing Address - Country:US
Mailing Address - Phone:714-452-5048
Mailing Address - Fax:714-844-9401
Practice Address - Street 1:11525 BROOKSHIRE AVE
Practice Address - Street 2:SUITE 400
Practice Address - City:DOWNEY
Practice Address - State:CA
Practice Address - Zip Code:90241-4985
Practice Address - Country:US
Practice Address - Phone:562-869-4497
Practice Address - Fax:562-869-6317
Is Sole Proprietor?:No
Enumeration Date:2006-11-24
Last Update Date:2017-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA54613207RC0200X, 207RP1001X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
H32656Medicare UPIN