Provider Demographics
NPI:1922063700
Name:GHILARDUCCI, MARK JOHN (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:JOHN
Last Name:GHILARDUCCI
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1203 FLYNN RD UNIT 160
Mailing Address - Street 2:
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93012-6203
Mailing Address - Country:US
Mailing Address - Phone:805-804-4168
Mailing Address - Fax:805-830-1177
Practice Address - Street 1:2221 WANKEL WAY
Practice Address - Street 2:
Practice Address - City:OXNARD
Practice Address - State:CA
Practice Address - Zip Code:93030-0192
Practice Address - Country:US
Practice Address - Phone:805-988-9366
Practice Address - Fax:805-483-3747
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2025-07-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG59002207XS0114X, 207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
No207XS0114XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryAdult Reconstructive Orthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG59002OtherSTATE LICENSE
CAE65590OtherUPIN
CAWG59002AMedicare PIN
CA0878110001Medicare NSC
CAW268Medicare PIN