Provider Demographics
NPI:1548278542
Name:EDDY, MARK DOUGLAS (PT OCS CSCS)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:DOUGLAS
Last Name:EDDY
Suffix:
Gender:M
Credentials:PT OCS CSCS
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Mailing Address - Street 1:8569 BOND RD
Mailing Address - Street 2:SUITE 150
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95624-9521
Mailing Address - Country:US
Mailing Address - Phone:916-714-1177
Mailing Address - Fax:
Practice Address - Street 1:601 UNIVERSITY AVE
Practice Address - Street 2:STE 185
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95825-6739
Practice Address - Country:US
Practice Address - Phone:916-927-1333
Practice Address - Fax:916-927-1586
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2017-12-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAPT22352225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPT223521Medicare ID - Type Unspecified