Provider Demographics
NPI:1164472833
Name:HALDEMAN, MARK T (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:T
Last Name:HALDEMAN
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 1:915 MICHIGAN ST
Mailing Address - Street 2:
Mailing Address - City:SIDNEY
Mailing Address - State:OH
Mailing Address - Zip Code:45365-2401
Mailing Address - Country:US
Mailing Address - Phone:937-497-5665
Mailing Address - Fax:937-497-5674
Practice Address - Street 1:1081 FAIRINGTON DR
Practice Address - Street 2:
Practice Address - City:SIDNEY
Practice Address - State:OH
Practice Address - Zip Code:45365-8130
Practice Address - Country:US
Practice Address - Phone:937-493-0009
Practice Address - Fax:937-492-6684
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2020-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-07-5865-H207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2143737Medicaid
OH0894649Medicare PIN
OH2143737Medicaid