1497857999 NPI number — MR. MARK M LESSNER M.D.

Table of content: MR. MARK M LESSNER M.D. (NPI 1497857999)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497857999 NPI number — MR. MARK M LESSNER M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LESSNER
Provider First Name:
MARK
Provider Middle Name:
M
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
M.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:
1497857999
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/19/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1079 EUCALYPTUS ST, SUITE#A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MANTECA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95337
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
209-239-6008
Provider Business Mailing Address Fax Number:
209-239-3408

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
601 W RIVERSIDE DR STE 2
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PARKER
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85344-5119
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-256-4110
Provider Business Practice Location Address Fax Number:
928-722-6113
Provider Enumeration Date:
09/04/2006

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: 207Q00000X , with the licence number:  G33868 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , with the licence number: 33868 , 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)

  • Identifier: 594551 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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