Provider Demographics
NPI:1174637995
Name:LEVENTER, MARK E (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:E
Last Name:LEVENTER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:PO BOX 246
Mailing Address - Street 2:
Mailing Address - City:GRASS LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:49240-0246
Mailing Address - Country:US
Mailing Address - Phone:517-522-8403
Mailing Address - Fax:517-522-4275
Practice Address - Street 1:12337 E MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:GRASS LAKE
Practice Address - State:MI
Practice Address - Zip Code:49240-0246
Practice Address - Country:US
Practice Address - Phone:517-522-8403
Practice Address - Fax:517-522-4275
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-18
Last Update Date:2020-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIML041377207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
0803800311OtherBCBS PPO
0803800311OtherBLUE CHOICE
MI2126585Medicaid
383042885OtherCIGNA CONNECTICUT GENERAL
383042885OtherCIGNA CONNECTICUT
0803800311OtherBCBS COMMUNITY BLUE
0803800311OtherBLUE CARE NETWORK
0803800311OtherBCBS BLUE CHOICE
0803800311OtherBCBS BLUE PREFERRED
MI0803800311OtherBCBS
383042885OtherCIGNA
383042885OtherCIGNA HEALTHCARE
383042885OtherCONSECO HEALTHCARE
383042885OtherCORESOURCE
383042885OtherCONTINENTAL LIFE
383042885OtherCONTINENTAL
0803800311OtherBCBS FEP PROGRAM
383042885OtherCONSECO
383042885OtherCORESOURCE
383042885OtherCONSECO