Provider Demographics
NPI:1245232800
Name:O'CONNOR, MARK (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:O'CONNOR
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 1:2409 CHERRY ST
Mailing Address - Street 2:STE 100
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43608-2625
Mailing Address - Country:US
Mailing Address - Phone:419-251-3700
Mailing Address - Fax:419-251-3835
Practice Address - Street 1:2409 CHERRY ST
Practice Address - Street 2:STE 100
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43608-2625
Practice Address - Country:US
Practice Address - Phone:419-251-3700
Practice Address - Fax:419-251-3835
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2009-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH350721050207RC0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4140805Medicaid
OH060056251OtherRAILROAD MEDICARE
OH2018846Medicaid
OH000000140670OtherANTHEM
OH02570OtherPARAMOUNT
MI1105810672OtherBLUE CROSS BLUE SHIELD MICHIGAN
OH060056251OtherRAILROAD MEDICARE
MI4140805Medicaid
MI1105810672OtherBLUE CROSS BLUE SHIELD MICHIGAN
OH0821347Medicare PIN