Provider Demographics
NPI:1245218973
Name:SOUDER, MARK STEVEN (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:STEVEN
Last Name:SOUDER
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 1:1310 E 7TH ST
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:IN
Mailing Address - Zip Code:46706-2534
Mailing Address - Country:US
Mailing Address - Phone:260-925-0305
Mailing Address - Fax:260-925-6041
Practice Address - Street 1:1310 E 7TH ST
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:IN
Practice Address - Zip Code:46706-2534
Practice Address - Country:US
Practice Address - Phone:260-925-0305
Practice Address - Fax:260-925-6041
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-03
Last Update Date:2008-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01026373A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
081664279OtherRR MEDICARE
IN100053210AMedicaid
000000083986OtherBCBS
IN055590Medicare PIN
081664279OtherRR MEDICARE
IN100053210AMedicaid