Provider Demographics
NPI:1306878020
Name:POPPER, MARK DAVID (PHD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:DAVID
Last Name:POPPER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1960 N. GATEWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93727
Mailing Address - Country:US
Mailing Address - Phone:559-266-5200
Mailing Address - Fax:559-266-5201
Practice Address - Street 1:1960 N. GATEWAY BLVD
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93727
Practice Address - Country:US
Practice Address - Phone:559-266-5200
Practice Address - Fax:559-266-5201
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2019-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY13574103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA562500594Medicare ID - Type UnspecifiedTAX ID