Provider Demographics
NPI:1578667713
Name:HAMILTON, MARK (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:HAMILTON
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:PO BOX 68952
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-0952
Mailing Address - Country:US
Mailing Address - Phone:317-870-6754
Mailing Address - Fax:317-870-0499
Practice Address - Street 1:533 E COUNTY LINE RD
Practice Address - Street 2:SUITE #104
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46143-1073
Practice Address - Country:US
Practice Address - Phone:317-859-3810
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-08
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01046689208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200186440Medicaid
G62946Medicare UPIN
IN200186440Medicaid