Provider Demographics
NPI:1831180587
Name:DAGDAGAN, MARK TAVITA (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:TAVITA
Last Name:DAGDAGAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:MARCELINO
Other - Middle Name:TAVITA
Other - Last Name:DAGDAGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 1139
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93302-1139
Mailing Address - Country:US
Mailing Address - Phone:661-371-2796
Mailing Address - Fax:661-438-1746
Practice Address - Street 1:5925 TRUXTUN AVE
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93309-0432
Practice Address - Country:US
Practice Address - Phone:661-638-2273
Practice Address - Fax:661-638-2288
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-02
Last Update Date:2018-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC42621207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C426210OtherCAL. MEDICARE PROVIDER NU
CA94499024Medicaid
CAC44710Medicare UPIN
CA00C426210OtherCAL. MEDICARE PROVIDER NU