Provider Demographics
NPI:1578567426
Name:MICHAEL, JOHN MARK (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:MARK
Last Name:MICHAEL
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 1:242 WILLOWGATE LN
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260-1431
Mailing Address - Country:US
Mailing Address - Phone:317-848-1611
Mailing Address - Fax:
Practice Address - Street 1:242 WILLOWGATE LN
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-1431
Practice Address - Country:US
Practice Address - Phone:317-848-1611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-09
Last Update Date:2016-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01033505207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN180007434OtherRAILROAD MEDICARE
IN100317670Medicaid
IN100317670Medicaid
0301750001Medicare NSC
IND70789Medicare UPIN