Provider Demographics
NPI:1538110648
Name:MASSIE, MARK S (DPM)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:S
Last Name:MASSIE
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:PO BOX 40450
Mailing Address - Street 2:
Mailing Address - City:BAY VILLAGE
Mailing Address - State:OH
Mailing Address - Zip Code:44140-0450
Mailing Address - Country:US
Mailing Address - Phone:440-871-4700
Mailing Address - Fax:440-871-4702
Practice Address - Street 1:15644 MADISON AVE
Practice Address - Street 2:106
Practice Address - City:LAKEWOOD
Practice Address - State:OH
Practice Address - Zip Code:44107-5622
Practice Address - Country:US
Practice Address - Phone:216-221-2445
Practice Address - Fax:216-221-5891
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-13
Last Update Date:2010-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3600307M213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2066204Medicaid
OHP00301287OtherMEDICARE RAILROAD PIN
OH2066204Medicaid
OH5702110001Medicare NSC
OH0856035Medicare PIN