Provider Demographics
NPI:1568572733
Name:DISTLER, MARK W (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:W
Last Name:DISTLER
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Gender:M
Credentials:MD
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Mailing Address - Street 1:301 MIDDLETOWN PARK PL
Mailing Address - Street 2:SUITE C
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40243-2515
Mailing Address - Country:US
Mailing Address - Phone:502-244-9858
Mailing Address - Fax:502-244-9575
Practice Address - Street 1:301 MIDDLETOWN PARK PL
Practice Address - Street 2:SUITE C
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40243-2515
Practice Address - Country:US
Practice Address - Phone:502-244-9858
Practice Address - Fax:502-244-9575
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2014-03-12
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Provider Licenses
StateLicense IDTaxonomies
IN1042652208000000X
KY28797208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100373990Medicaid