Basic Information
| Provider Information | |||||||||
| NPI: | 1497780563 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HABERMAN | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | D. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 332 S JUNIPER ST STE 100 | ||||||||
| Address2: | |||||||||
| City: | ESCONDIDO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920254941 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8662282236 | ||||||||
| FaxNumber: | 7607373430 | ||||||||
| Practice Location | |||||||||
| Address1: | 225 E 2ND AVE | ||||||||
| Address2: | |||||||||
| City: | ESCONDIDO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920254212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7602916700 | ||||||||
| FaxNumber: | 7607373430 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2006 | ||||||||
| LastUpdateDate: | 11/18/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | G83540 | CA | N | Allopathic & Osteopathic Physicians | Pediatrics | 207R00000X | G83540 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 110231975 | 01 | CA | MEDICARE RR | OTHER | 00G835400 | 01 | CA | BLUE SHIELD | OTHER |