Provider Demographics
NPI:1093715062
Name:JENSEN, MARK A (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:A
Last Name:JENSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2217 DUBOIS DR
Mailing Address - Street 2:
Mailing Address - City:WARSAW
Mailing Address - State:IN
Mailing Address - Zip Code:46580-3212
Mailing Address - Country:US
Mailing Address - Phone:574-267-8940
Mailing Address - Fax:574-267-5782
Practice Address - Street 1:2217 DUBOIS DR
Practice Address - Street 2:
Practice Address - City:WARSAW
Practice Address - State:IN
Practice Address - Zip Code:46580-3212
Practice Address - Country:US
Practice Address - Phone:574-267-8940
Practice Address - Fax:574-267-5782
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2009-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01033577174400000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100157230AMedicaid
INC25008Medicare UPIN
IN262490GMedicare PIN
453220VMedicare PIN
452000Medicare PIN