Provider Demographics
NPI:1528158664
Name:VENTOCILLA, MARK AUGUSTO (OD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:AUGUSTO
Last Name:VENTOCILLA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:613 E GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92025-4402
Mailing Address - Country:US
Mailing Address - Phone:760-747-7979
Mailing Address - Fax:760-747-7799
Practice Address - Street 1:613 E GRAND AVE
Practice Address - Street 2:
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92025-4402
Practice Address - Country:US
Practice Address - Phone:760-747-4797
Practice Address - Fax:760-747-7799
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2012-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003734152W00000X
FLOPC 3532152W00000X
CA10435152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4454950Medicaid
MI4820570Medicaid
MI900F165350OtherBCBS LAKESHORE EYECARE
MI90G011590OtherBCBS ELDER EYECARE GROUP
MIOP24730Medicare UPIN
MI4820570Medicaid