Provider Demographics
NPI:1912057381
Name:AUSTERLITZ, MARK S (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:S
Last Name:AUSTERLITZ
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 1:7485 MISSION VALLEY RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-4422
Mailing Address - Country:US
Mailing Address - Phone:619-819-7100
Mailing Address - Fax:619-819-7101
Practice Address - Street 1:7485 MISSION VALLEY RD
Practice Address - Street 2:SUITE 103
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-4422
Practice Address - Country:US
Practice Address - Phone:619-819-7100
Practice Address - Fax:619-819-7101
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG33220207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G332200OtherBLUE SHIELD
CAG33220Medicare ID - Type Unspecified
CA00G332200OtherBLUE SHIELD