Provider Demographics
NPI:1205866647
Name:CRNKOVICH, MARK J (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:J
Last Name:CRNKOVICH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 182039
Mailing Address - Street 2:DEPT 086
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43218-2039
Mailing Address - Country:US
Mailing Address - Phone:614-261-3712
Mailing Address - Fax:614-447-9593
Practice Address - Street 1:3525 OLENTANGY RIVER RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43214-3937
Practice Address - Country:US
Practice Address - Phone:614-566-5000
Practice Address - Fax:614-566-6958
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH350522542085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000118957OtherANTHEM
OH0644477Medicaid
E29717Medicare UPIN
CR0641171Medicare ID - Type Unspecified