Provider Demographics
NPI:1649244286
Name:MARK, RICHARD (DO)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:MARK
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 1:9398 N LILLEY RD
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MI
Mailing Address - Zip Code:48170-4610
Mailing Address - Country:US
Mailing Address - Phone:734-254-0453
Mailing Address - Fax:734-459-1855
Practice Address - Street 1:9398 N LILLEY RD
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-4610
Practice Address - Country:US
Practice Address - Phone:734-254-0453
Practice Address - Fax:734-459-1855
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2009-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101009615207Q00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1649244286Medicaid
MIP35120067Medicare PIN
MI1649244286Medicaid