Provider Demographics
NPI:1407010630
Name:MABUS, MARK S (MD, RPH)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:S
Last Name:MABUS
Suffix:
Gender:M
Credentials:MD, RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:935 E SNYDER AVE
Practice Address - Street 2:
Practice Address - City:MONTPELIER
Practice Address - State:OH
Practice Address - Zip Code:43543-1251
Practice Address - Country:US
Practice Address - Phone:419-485-3106
Practice Address - Fax:419-485-8776
Is Sole Proprietor?:No
Enumeration Date:2008-07-16
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.092452207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH00769943OtherRAILROAD