NPIMap

Individual provider Active NPI

Mark Todd Roback, DO

  • General Practice Physician
  • Fortuna, CA
National Provider Identifier
1801969829
Registry record updated Aug 25, 2014
On this page

Key facts

NPPES NPI Registry
Primary specialty
General Practice PhysicianTaxonomy code 208D00000X
License
20A10324 Issued in CA
Practice address
3304 Renner Dr
Fortuna, CA 95540-7102
Phone
(707) 725-4477
Fax
(707) 725-9209
NPI assigned
Nov 16, 2006
Last updated
Aug 25, 2014By the provider in NPPES
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Aug 25, 2014

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X R1153 KY
General Practice Physician 208D00000X 20A10324 CA Primary

Addresses

Primary practice location

3304 Renner Dr
Fortuna, CA 95540-7102

Mailing address

670 9TH Street
Suite 203
Arcata, CA 95521-6249
Phone (707) 826-8633

Other identifiers 3

IdentifierTypeStateIssuer
7100028230MedicaidKY
R1153OtherKYTEMP LICENSE
1801969829OtherCANPI

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in CA
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20080731000716 CA Practitioner - Family Practice 7214034552 Reassigns benefits to 2 organizations

Care Compare profile

Medicare Care Compare
Specialty
Family Practice
Education
Other, 2004
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices

Practice addresses (Care Compare)

1355 E St
Suite 200
Redding, CA 96001-0801
Phone (530) 605-4260

Hospital & facility affiliations

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Osteopathy

State licenses

LicenseStateTypeSpecialty
20A10324CAMDGeneral Practice Physician

Practice roles

OrganizationSpecialtyStatusNew patients
Galen Inpatient Physicians Inc CurrentSince Apr 1, 2016 Accepting new patients
Galen Inpatient Physicians PC CurrentSince Apr 1, 2016 Accepting new patients
Shasta Regional Medical Group Inc CurrentSince Feb 1, 2017 Accepting new patients
Shasta Regional Medical Group, Inc Family Medicine CurrentSince Feb 1, 2017 Accepting new patients
Orna Gil MD Inc Current Accepting new patients
Galen Inpatient Physicians, PC Current Accepting new patients

Locations

115 Mall Dr
Hanford, CA 93230
Phone (559) 537-0550

1601 Cummins Dr
Ste D
Modesto, CA 95358
Phone (510) 350-2663

1801 W Olympic Blvd
#1640
Pasadena, CA 91199

1100 Butte St
Redding, CA 96001
Phone (530) 227-6361

1355 East St
Ste 200
Redding, CA 96001
Phone (530) 229-2940

2175 Rosaline Ave
Redding, CA 96001
Phone (530) 225-7247

15248 Eleventh St
Victorville, CA 92395
Phone (760) 245-8691

Interoperability endpoints

  • FHIR API: https://fhir4.healow.com/fhir/r4/ABEFCA
  • Direct secure messaging: mark.roback.p3@direct.smmg.nextgenshare.com

Organizations & group practices 6

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

Hospital & facility affiliations 6

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1163635200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1408924800000",
    "number": "1801969829",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "670 9TH STREET",
            "address_2": "SUITE 203",
            "city": "ARCATA",
            "state": "CA",
            "postal_code": "955216249",
            "telephone_number": "707-826-8633",
            "fax_number": "707-826-8638"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3304 RENNER DR",
            "city": "FORTUNA",
            "state": "CA",
            "postal_code": "955407102",
            "telephone_number": "707-725-4477",
            "fax_number": "707-725-9209"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "ROBACK",
        "first_name": "MARK",
        "middle_name": "TODD",
        "credential": "DO",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-11-16",
        "last_updated": "2014-08-25",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "KY",
            "license": "R1153",
            "primary": false
        },
        {
            "code": "208D00000X",
            "taxonomy_group": "",
            "desc": "General Practice",
            "state": "CA",
            "license": "20A10324",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "7100028230",
            "state": "KY"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "TEMP LICENSE",
            "identifier": "R1153",
            "state": "KY"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NPI",
            "identifier": "1801969829",
            "state": "CA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Fortuna, CA

Sources for this page

Verify at the official NPI Registry.