Active NPI
Mark L Ettenhofer, PHD
- Clinical Psychologist
- San Diego, CA
National Provider Identifier
1922480755
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Clinical Psychologist
- License
- 04643
- Practice address
- 34800 Bob Wilson Dr
San Diego, CA 92134-1098 - Phone
- (301) 678-3321
- NPI assigned
- Jun 29, 2015
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 2
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Clinical Neuropsychologist | 103G00000X | 04643 | MD | |
| Clinical Psychologist | 103TC0700X | 04643 | MD | Primary |
Addresses
Primary practice location
34800 Bob Wilson Dr
San Diego, CA 92134-1098
Mailing address
34800 Bob Wilson Dr
San Diego, CA 92134-1098
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
- Credentials
- Doctor of Philosophy
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 04643 | MD | MD | Speech-Language Pathologist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1435536000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1710460800000",
"number": "1922480755",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "34800 BOB WILSON DR",
"city": "SAN DIEGO",
"state": "CA",
"postal_code": "921341098"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "34800 BOB WILSON DR",
"city": "SAN DIEGO",
"state": "CA",
"postal_code": "921341098",
"telephone_number": "301-678-3321"
}
],
"practiceLocations": [],
"basic": {
"last_name": "ETTENHOFER",
"first_name": "MARK",
"middle_name": "L",
"credential": "PHD",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2015-06-29",
"last_updated": "2024-03-15",
"certification_date": "2024-03-15",
"status": "A"
},
"taxonomies": [
{
"code": "103G00000X",
"taxonomy_group": "",
"desc": "Clinical Neuropsychologist",
"state": "MD",
"license": "04643",
"primary": false
},
{
"code": "103TC0700X",
"taxonomy_group": "",
"desc": "Psychologist, Clinical",
"state": "MD",
"license": "04643",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in San Diego, CA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 15, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.