Provider Demographics
NPI:1700411634
Name:MKT MD
Entity Type:Organization
Organization Name:MKT MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:MITHILESH
Authorized Official - Middle Name:K
Authorized Official - Last Name:TAMIRISA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:419-410-4898
Mailing Address - Street 1:516 RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:ROSSFORD
Mailing Address - State:OH
Mailing Address - Zip Code:43460-1055
Mailing Address - Country:US
Mailing Address - Phone:419-410-4898
Mailing Address - Fax:
Practice Address - Street 1:516 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:ROSSFORD
Practice Address - State:OH
Practice Address - Zip Code:43460-1055
Practice Address - Country:US
Practice Address - Phone:419-410-4898
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-11
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty