1306255963 NPI number — DR. MARK RANDOLPH MORTON PH.D.

Table of content: DR. MARK RANDOLPH MORTON PH.D. (NPI 1306255963)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306255963 NPI number — DR. MARK RANDOLPH MORTON PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MORTON
Provider First Name:
MARK
Provider Middle Name:
RANDOLPH
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PH.D.
Provider Gender Code:
M

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:
1306255963
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/07/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1881 COMMERCENTER E
Provider Second Line Business Mailing Address:
SUITE 232
Provider Business Mailing Address City Name:
SAN BERNARDINO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92408-3456
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-890-4466
Provider Business Mailing Address Fax Number:
909-890-4278

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1881 COMMERCENTER E
Provider Second Line Business Practice Location Address:
SUITE 232
Provider Business Practice Location Address City Name:
SAN BERNARDINO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92408-3456
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-890-4466
Provider Business Practice Location Address Fax Number:
909-890-4278
Provider Enumeration Date:
08/07/2014

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 106H00000X , with the licence number:  80852 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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