Provider Demographics
NPI:1124042999
Name:SECOR, MARK RICHARD (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:RICHARD
Last Name:SECOR
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 1:191A GLADES RD.
Mailing Address - Street 2:
Mailing Address - City:BEREA
Mailing Address - State:KY
Mailing Address - Zip Code:40403-1742
Mailing Address - Country:US
Mailing Address - Phone:859-986-1679
Mailing Address - Fax:859-986-1040
Practice Address - Street 1:191A GLADES RD.
Practice Address - Street 2:
Practice Address - City:BEREA
Practice Address - State:KY
Practice Address - Zip Code:40403-1742
Practice Address - Country:US
Practice Address - Phone:859-986-1679
Practice Address - Fax:859-986-1040
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY23629207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64236292Medicaid
4612084OtherAETNA
000000068790OtherANTHEM
3926Medicare ID - Type Unspecified
4612084OtherAETNA