1003523275 NPI number — ST. MARK MEDICAL TRANSPORT LLC

Table of content: DEREK JEN KON LOUIE BS, MS, OD (NPI 1235281379)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003523275 NPI number — ST. MARK MEDICAL TRANSPORT LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ST. MARK MEDICAL TRANSPORT LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1003523275
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/23/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
455 HICKEY BLVD STE 521
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALY CITY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94015-2631
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
650-483-2169
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
207 S MAPLE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTH SAN FRANCISCO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94080-6305
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
650-880-2588
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/27/2022

Additional Information

Authorized Official

Authorized Official Last Name:
IGNACIO
Authorized Official First Name:
MARK VICTOR
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/CEO
Authorized Official Telephone Number:
650-483-2169

Provider Taxonomy Codes

  • Taxonomy code: 343900000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 341600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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