Provider Demographics
NPI:1467482034
Name:GRESLA, MARK S (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:S
Last Name:GRESLA
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:PO BOX 151
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IN
Mailing Address - Zip Code:46733-0151
Mailing Address - Country:US
Mailing Address - Phone:260-724-2145
Mailing Address - Fax:260-728-3853
Practice Address - Street 1:955 HIGH ST
Practice Address - Street 2:SUITE 3
Practice Address - City:DECATUR
Practice Address - State:IN
Practice Address - Zip Code:46733-2326
Practice Address - Country:US
Practice Address - Phone:260-724-2125
Practice Address - Fax:260-724-3859
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-03
Last Update Date:2019-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01034460A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN9131OtherNO. IN PHP
IN100146990AMedicaid
IN000000087488OtherANTHEM PIN
IN9131OtherNO. IN PHP
IN100146990AMedicaid