Provider Demographics
NPI:1710997390
Name:MICHAEL, MARK (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:MICHAEL
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 1:5757 GLENWAY AVE
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45238-2105
Mailing Address - Country:US
Mailing Address - Phone:513-451-6006
Mailing Address - Fax:513-451-6036
Practice Address - Street 1:5757 GLENWAY AVE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45238-2105
Practice Address - Country:US
Practice Address - Phone:513-451-6006
Practice Address - Fax:513-451-6036
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2011-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35052345207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH030004895OtherMEDICARE RAILROAD
OH030004895OtherMEDICARE RAILROAD
OHA16849Medicare UPIN