Provider Demographics
NPI:1639197049
Name:FENSTER, MARK E (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:E
Last Name:FENSTER
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 1:5300 FAR HILLS AVE.
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45429-2347
Mailing Address - Country:US
Mailing Address - Phone:937-433-7536
Mailing Address - Fax:937-433-9612
Practice Address - Street 1:5300 FAR HILLS AVE.
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45429-2347
Practice Address - Country:US
Practice Address - Phone:937-433-7536
Practice Address - Fax:937-433-9612
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2016-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35072837F207ND0101X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0968011OtherAETNA
OH3109647743A20OtherANTHEM BLUE SHIELD
OH0300382OtherUNITED HEALTH CARE
OHFE0838371Medicare ID - Type Unspecified
OH3109647743A20OtherANTHEM BLUE SHIELD