Provider Demographics
NPI:1477566172
Name:SQUIRE, MARK A (DPM)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:SQUIRE
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HENRY FORD HEALTH SYSTEM
Mailing Address - Street 2:29200 SCHOOLCRAFT
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48150
Mailing Address - Country:US
Mailing Address - Phone:734-523-1050
Mailing Address - Fax:
Practice Address - Street 1:HENRY FORD HEALTH SYSTEM
Practice Address - Street 2:29200 SCHOOLCRAFT
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48150
Practice Address - Country:US
Practice Address - Phone:734-523-1050
Practice Address - Fax:734-523-2464
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901000917213ES0103X, 213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
480H280180OtherBLUE CROSS-BLUE CROSS
MS000917OtherCOMMERCIAL-COMMERCIAL NUMBER
MS000917OtherCHAMPUS-CHAMPUS
MI462104813Medicaid