Provider Demographics
NPI:1639433261
Name:PELL, MARK DAVID (DPM)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:DAVID
Last Name:PELL
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:PO BOX 635283
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-5283
Mailing Address - Country:US
Mailing Address - Phone:592-120-1758
Mailing Address - Fax:859-655-8911
Practice Address - Street 1:1500 JAMES SIMPSON JR WAY
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:KY
Practice Address - Zip Code:41011-0801
Practice Address - Country:US
Practice Address - Phone:859-212-0175
Practice Address - Fax:859-655-8911
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-28
Last Update Date:2021-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC006335213ES0103X
KY243972213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100640210Medicaid
OH0382069Medicaid