Provider Demographics
NPI:1619031192
Name:DEMUTH, MARK EVAN (DO)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:EVAN
Last Name:DEMUTH
Suffix:
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 1:1342 AMANDAJO DR
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-4629
Mailing Address - Country:US
Mailing Address - Phone:270-307-1114
Mailing Address - Fax:
Practice Address - Street 1:619 W MAIN ST
Practice Address - Street 2:
Practice Address - City:CLARKSON
Practice Address - State:KY
Practice Address - Zip Code:42726-7044
Practice Address - Country:US
Practice Address - Phone:186-665-3823
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2009-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036110355207Q00000X
KY03097207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine