Provider Demographics
NPI:1508802273
Name:TRUAX, MARK A (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:TRUAX
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 1:2705 N LEBANON ST STE 305
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:IN
Mailing Address - Zip Code:46052-8622
Mailing Address - Country:US
Mailing Address - Phone:765-485-8852
Mailing Address - Fax:
Practice Address - Street 1:1000 N LEBANON ST
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:IN
Practice Address - Zip Code:46147-9372
Practice Address - Country:US
Practice Address - Phone:765-676-5754
Practice Address - Fax:765-676-9853
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2021-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01032015207Q00000X
IN01032015A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100324100Medicaid
IN100324100Medicaid
C25370Medicare UPIN
INM471400013OtherMEDICARE PROVIDER PTAN