Provider Demographics
NPI:1225070444
Name:SANDOCK, MARK S (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:S
Last Name:SANDOCK
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 1:600 EAST BLVD
Mailing Address - Street 2:ADMINISTRATION
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46514-2483
Mailing Address - Country:US
Mailing Address - Phone:574-296-2925
Mailing Address - Fax:574-523-3495
Practice Address - Street 1:600 EAST BLVD
Practice Address - Street 2:ADMINISTRATION
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-2483
Practice Address - Country:US
Practice Address - Phone:574-296-2925
Practice Address - Fax:574-523-3495
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2010-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01024361207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN021236800OtherFEDERAL BLACK LUNG
IN100220640AMedicaid
IN000000215929OtherBCBS
IN100220640AMedicaid
C2553Medicare UPIN
IN187720EMedicare PIN