Provider Demographics
NPI:1700868718
Name:SOFONIO, MARK VINCENT (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:VINCENT
Last Name:SOFONIO
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 1:39000 BOB HOPE DR
Mailing Address - Street 2:STE 407 KIEWIT
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270-3221
Mailing Address - Country:US
Mailing Address - Phone:760-341-5555
Mailing Address - Fax:760-341-8054
Practice Address - Street 1:39000 BOB HOPE DR
Practice Address - Street 2:STE 407 KIEWIT
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270-3221
Practice Address - Country:US
Practice Address - Phone:760-341-5555
Practice Address - Fax:760-341-8054
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-16
Last Update Date:2017-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG070699208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G706990Medicare ID - Type Unspecified
F68114Medicare UPIN