Provider Demographics
NPI:1295382208
Name:KASELAK, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:KASELAK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3855 EDGEWATER DR
Mailing Address - Street 2:
Mailing Address - City:VERMILION
Mailing Address - State:OH
Mailing Address - Zip Code:44089-2281
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1939 OBERLIN AVE
Practice Address - Street 2:
Practice Address - City:LORAIN
Practice Address - State:OH
Practice Address - Zip Code:44052-3959
Practice Address - Country:US
Practice Address - Phone:440-963-7042
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-23
Last Update Date:2019-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist