Provider Demographics
NPI:1306814678
Name:DAVIS, MARK EUGENE (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:EUGENE
Last Name:DAVIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1069 DELAWARE AVE
Mailing Address - Street 2:SUITE 205B
Mailing Address - City:MARION
Mailing Address - State:OH
Mailing Address - Zip Code:43302-1400
Mailing Address - Country:US
Mailing Address - Phone:740-387-4578
Mailing Address - Fax:740-387-8638
Practice Address - Street 1:1069 DELAWARE AVE
Practice Address - Street 2:SUITE 205B
Practice Address - City:MARION
Practice Address - State:OH
Practice Address - Zip Code:43302-1400
Practice Address - Country:US
Practice Address - Phone:740-387-4578
Practice Address - Fax:740-387-8638
Is Sole Proprietor?:No
Enumeration Date:2006-03-10
Last Update Date:2012-07-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH35060844207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0816148Medicaid
0684555Medicare ID - Type Unspecified
OH0816148Medicaid