Provider Demographics
NPI:1255331138
Name:ANSTADT, MARK P (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:P
Last Name:ANSTADT
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:P.O. BOX 407
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45409
Mailing Address - Country:US
Mailing Address - Phone:937-208-6060
Mailing Address - Fax:937-208-6061
Practice Address - Street 1:30 E APPLE ST STE 4256
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45409-2939
Practice Address - Country:US
Practice Address - Phone:937-208-6060
Practice Address - Fax:937-208-6061
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-21
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-056443 A208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0689992Medicaid
OHAN4129331Medicare ID - Type Unspecified
OH0689992Medicaid