Provider Demographics
NPI:1255322509
Name:O'BRIEN, MARK T (DO)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:T
Last Name:O'BRIEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1280 S 9TH ST
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR
Mailing Address - State:MI
Mailing Address - Zip Code:48079-5368
Mailing Address - Country:US
Mailing Address - Phone:810-326-0837
Mailing Address - Fax:810-326-1534
Practice Address - Street 1:1280 S 9TH ST
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR
Practice Address - State:MI
Practice Address - Zip Code:48079-5368
Practice Address - Country:US
Practice Address - Phone:810-326-0837
Practice Address - Fax:810-326-1534
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-03
Last Update Date:2022-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101009744207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2662631Medicaid
MI57400775082Medicare ID - Type Unspecified
MIE49635Medicare UPIN