Provider Demographics
NPI:1003011834
Name:SNIADANKO, MARK (DO)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:SNIADANKO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4750 HEMPSTEAD STATION DR
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45429-5164
Mailing Address - Country:US
Mailing Address - Phone:800-875-0136
Mailing Address - Fax:937-619-3014
Practice Address - Street 1:2600 NAVARRE AVE
Practice Address - Street 2:
Practice Address - City:OREGON
Practice Address - State:OH
Practice Address - Zip Code:43616-3207
Practice Address - Country:US
Practice Address - Phone:419-696-7500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-20
Last Update Date:2008-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34-008693207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2782743Medicaid
OH000000522688OtherBCBS ST CHARLES
OHP00435623OtherRRN MCR ST CHARLES
OHP00435623OtherRRN MCR ST CHARLES
OH2782743Medicaid