Provider Demographics
NPI:1669497806
Name:SKIBA, MARK C (MD , PHD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:C
Last Name:SKIBA
Suffix:
Gender:M
Credentials:MD , PHD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 GROVE ST
Mailing Address - Street 2:STE 305
Mailing Address - City:FRANKLIN
Mailing Address - State:MA
Mailing Address - Zip Code:02038-3156
Mailing Address - Country:US
Mailing Address - Phone:508-528-5392
Mailing Address - Fax:508-541-2420
Practice Address - Street 1:14 PROSPECT ST
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:MA
Practice Address - Zip Code:01757-3003
Practice Address - Country:US
Practice Address - Phone:508-473-1190
Practice Address - Fax:508-482-5416
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA206991207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0199214Medicaid
A34281Medicare ID - Type Unspecified
MA0199214Medicaid