Provider Demographics
NPI:1083325104
Name:DEETER, MARK (MBA)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:DEETER
Suffix:
Gender:M
Credentials:MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3559 STANFORD PL
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45406-3641
Mailing Address - Country:US
Mailing Address - Phone:937-723-6893
Mailing Address - Fax:
Practice Address - Street 1:2400 W STROOP RD
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45439-2041
Practice Address - Country:US
Practice Address - Phone:937-723-6893
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-09
Last Update Date:2022-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator