Provider Demographics
NPI:1801896675
Name:MARDIAT, JOHN GEORGE (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:GEORGE
Last Name:MARDIAT
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:PO BOX 30820
Mailing Address - Street 2:
Mailing Address - City:SANTA BARBARA
Mailing Address - State:CA
Mailing Address - Zip Code:93130-0820
Mailing Address - Country:US
Mailing Address - Phone:805-448-5825
Mailing Address - Fax:805-569-0079
Practice Address - Street 1:316 W JUNIPERO ST
Practice Address - Street 2:
Practice Address - City:SANTA BARBARA
Practice Address - State:CA
Practice Address - Zip Code:93105-4305
Practice Address - Country:US
Practice Address - Phone:805-448-5825
Practice Address - Fax:805-569-0079
Is Sole Proprietor?:No
Enumeration Date:2005-07-22
Last Update Date:2012-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG443932085R0202X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G443930Medicaid
CADP019YMedicare PIN
A49633Medicare UPIN
CADP019XMedicare PIN
WG44393CMedicare ID - Type Unspecified
FLFR841ZMedicare PIN