Provider Demographics
NPI:1255325718
Name:FELDMAN, MARK R (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:R
Last Name:FELDMAN
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 1:2551 S SMITH RD
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-8943
Mailing Address - Country:US
Mailing Address - Phone:812-277-5311
Mailing Address - Fax:
Practice Address - Street 1:2551 S SMITH RD
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47401-8943
Practice Address - Country:US
Practice Address - Phone:812-277-5311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-09
Last Update Date:2015-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA37989207V00000X
IN01050576A207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200228890AMedicaid
IN200228890AMedicaid
IA154470012Medicare PIN
IA1255325718Medicaid
INA09994Medicare UPIN
IN940070WWWWMedicare ID - Type Unspecified