Provider Demographics
NPI:1568953800
Name:DOE, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:DOE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 FELLSWAY W APT 3
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-2061
Mailing Address - Country:US
Mailing Address - Phone:215-431-9346
Mailing Address - Fax:
Practice Address - Street 1:730 EASTERN AVE
Practice Address - Street 2:
Practice Address - City:MALDEN
Practice Address - State:MA
Practice Address - Zip Code:02148-5906
Practice Address - Country:US
Practice Address - Phone:781-395-0704
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-22
Last Update Date:2018-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health