Provider Demographics
NPI:1689664070
Name:STANISH, MARK S (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:S
Last Name:STANISH
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:4440 NORTH PORTAGE AVENUE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46628-9570
Mailing Address - Country:US
Mailing Address - Phone:574-204-6200
Mailing Address - Fax:574-239-1520
Practice Address - Street 1:4440 NORTH PORTAGE AVENUE
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46628-9570
Practice Address - Country:US
Practice Address - Phone:574-204-6200
Practice Address - Fax:574-239-1520
Is Sole Proprietor?:No
Enumeration Date:2005-10-26
Last Update Date:2016-08-03
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IN01039400A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100092000Medicaid
IN100092000Medicaid
INA73301Medicare UPIN