Provider Demographics
NPI:1407845746
Name:EVENSON, MARK (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:EVENSON
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 1:1000 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:TIPTON
Mailing Address - State:IN
Mailing Address - Zip Code:46072-9753
Mailing Address - Country:US
Mailing Address - Phone:765-675-8521
Mailing Address - Fax:765-675-8520
Practice Address - Street 1:1000 S MAIN ST
Practice Address - Street 2:
Practice Address - City:TIPTON
Practice Address - State:IN
Practice Address - Zip Code:46072-9753
Practice Address - Country:US
Practice Address - Phone:765-675-8521
Practice Address - Fax:765-675-8520
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-19
Last Update Date:2011-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01032279207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100234260AMedicaid
IN000000603583OtherANTHEM - TIPTON HOSPITAL
IN100234260AMedicaid