Provider Demographics
NPI:1699859017
Name:DEMIDOVICH, MARK A (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:A
Last Name:DEMIDOVICH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:233 GEORGE JUNIOR RD
Mailing Address - Street 2:
Mailing Address - City:GROVE CITY
Mailing Address - State:PA
Mailing Address - Zip Code:16127-4417
Mailing Address - Country:US
Mailing Address - Phone:724-421-3355
Mailing Address - Fax:724-406-0240
Practice Address - Street 1:233 GEORGE JUNIOR RD
Practice Address - Street 2:
Practice Address - City:GROVE CITY
Practice Address - State:PA
Practice Address - Zip Code:16127
Practice Address - Country:US
Practice Address - Phone:724-421-3355
Practice Address - Fax:724-406-0240
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2018-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD4272222084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1879793OtherHIGHMARK PROVIDER #