Provider Demographics
NPI:1780235986
Name:YACO, MARK JOHN FERNANDO (PT, DPT)
Entity type:Individual
Prefix:
First Name:MARK JOHN
Middle Name:FERNANDO
Last Name:YACO
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 WASHINGTON AVE APT 705
Mailing Address - Street 2:
Mailing Address - City:TOWSON
Mailing Address - State:MD
Mailing Address - Zip Code:21204-4720
Mailing Address - Country:US
Mailing Address - Phone:443-722-4367
Mailing Address - Fax:
Practice Address - Street 1:2401 W BELVEDERE AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21215-5216
Practice Address - Country:US
Practice Address - Phone:410-601-4360
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-28
Last Update Date:2019-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD21885225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist