Provider Demographics
NPI:1326156746
Name:MONSOUR, MARK A (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:MONSOUR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:6680 POE AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45414-2855
Mailing Address - Country:US
Mailing Address - Phone:937-280-8400
Mailing Address - Fax:937-280-8373
Practice Address - Street 1:2350 MIAMI VALLEY DR STE 500
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45459-4780
Practice Address - Country:US
Practice Address - Phone:937-293-1622
Practice Address - Fax:937-245-6308
Is Sole Proprietor?:No
Enumeration Date:2006-08-27
Last Update Date:2022-01-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH35076223208800000X
OH35.076223208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2115311Medicaid
OH0877041Medicare PIN
OH0877043Medicare PIN
OHG38954Medicare UPIN