Provider Demographics
NPI:1689638322
Name:MIDDENDORF, MARK EDWARD (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:EDWARD
Last Name:MIDDENDORF
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Gender:M
Credentials:MD
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Mailing Address - Street 1:2300 CHAMBER CENTER DR
Mailing Address - Street 2:
Mailing Address - City:LAKESIDE PARK
Mailing Address - State:KY
Mailing Address - Zip Code:41017-1673
Mailing Address - Country:US
Mailing Address - Phone:859-344-5555
Mailing Address - Fax:859-655-4395
Practice Address - Street 1:5522 TAYLOR MILL RD
Practice Address - Street 2:
Practice Address - City:TAYLOR MILL
Practice Address - State:KY
Practice Address - Zip Code:41015-2264
Practice Address - Country:US
Practice Address - Phone:857-491-2855
Practice Address - Fax:859-655-4395
Is Sole Proprietor?:No
Enumeration Date:2006-04-12
Last Update Date:2015-09-28
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Provider Licenses
StateLicense IDTaxonomies
KY20166207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0461441Medicaid
KY64201668Medicaid
KY64201668Medicaid
KYC74358Medicare UPIN
KY080179265Medicare PIN