Provider Demographics
NPI:1578698494
Name:STABILE, MARK L JR (DO)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:L
Last Name:STABILE
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:149 E MAIN ST
Mailing Address - Street 2:BOX 1117
Mailing Address - City:ANDOVER
Mailing Address - State:OH
Mailing Address - Zip Code:44003-9479
Mailing Address - Country:US
Mailing Address - Phone:440-293-5555
Mailing Address - Fax:440-293-6643
Practice Address - Street 1:149 E MAIN ST
Practice Address - Street 2:BOX 1117
Practice Address - City:ANDOVER
Practice Address - State:OH
Practice Address - Zip Code:44003-9479
Practice Address - Country:US
Practice Address - Phone:440-293-5555
Practice Address - Fax:440-293-6643
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2009-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34008591207Q00000X
PAOS012755207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1760675OtherHIGHMARK BCBS-OH LOCATION
PA410793OtherUPMC
PA1759651OtherHIGHMARK BCBS- PA LOCATIO
OH341757611029OtherCARESOURCE
OH2641314Medicaid
I36334Medicare UPIN
PA093054QGBMedicare ID - Type Unspecified
OH2641314Medicaid