Provider Demographics
NPI:1033100284
Name:ROUNSAVILLE, MARK CARLTON (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:CARLTON
Last Name:ROUNSAVILLE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 LOS PINOS
Mailing Address - Street 2:
Mailing Address - City:NICASIO
Mailing Address - State:CA
Mailing Address - Zip Code:94946
Mailing Address - Country:US
Mailing Address - Phone:415-662-2669
Mailing Address - Fax:415-662-2669
Practice Address - Street 1:45 LOS PINOS
Practice Address - Street 2:
Practice Address - City:NICASIO
Practice Address - State:CA
Practice Address - Zip Code:94946
Practice Address - Country:US
Practice Address - Phone:415-662-2669
Practice Address - Fax:415-662-2669
Is Sole Proprietor?:No
Enumeration Date:2005-11-04
Last Update Date:2022-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA390602085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A390600OtherBLUE SHIELD
CA00A390600Medicaid
CA00A390601Medicare PIN
CAA28804Medicare UPIN