Provider Demographics
NPI:1164384335
Name:FADIL, MARK (CMP)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:FADIL
Suffix:
Gender:M
Credentials:CMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2005 PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:PALO ALTO
Mailing Address - State:CA
Mailing Address - Zip Code:94306-1143
Mailing Address - Country:US
Mailing Address - Phone:650-823-1091
Mailing Address - Fax:
Practice Address - Street 1:260 SHERIDAN AVE STE B40
Practice Address - Street 2:
Practice Address - City:PALO ALTO
Practice Address - State:CA
Practice Address - Zip Code:94306-2054
Practice Address - Country:US
Practice Address - Phone:650-823-1091
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-11-26
Last Update Date:2025-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA29031225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist