Provider Demographics
NPI:1407848435
Name:SPITZER, MARK STEVEN
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:STEVEN
Last Name:SPITZER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 DATA DR
Mailing Address - Street 2:
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95670-7956
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:410 E YOSEMITE AVE
Practice Address - Street 2:STE B
Practice Address - City:MERCED
Practice Address - State:CA
Practice Address - Zip Code:95340-8489
Practice Address - Country:US
Practice Address - Phone:209-722-9272
Practice Address - Fax:209-724-9329
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-16
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A5347207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX53471Medicaid
E08916Medicare UPIN
CA00AX53471Medicaid