Provider Demographics
NPI:1740220854
Name:CORCORAN, MARK E (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:E
Last Name:CORCORAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:392 E STONEQUARRY RD STE 441
Mailing Address - Street 2:
Mailing Address - City:VANDALIA
Mailing Address - State:OH
Mailing Address - Zip Code:45377-9677
Mailing Address - Country:US
Mailing Address - Phone:937-308-0056
Mailing Address - Fax:
Practice Address - Street 1:512 S BURNETT RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45505-2720
Practice Address - Country:US
Practice Address - Phone:937-328-3385
Practice Address - Fax:937-328-3387
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2019-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.053772208M00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0629341Medicaid
OH0620204Medicare PIN
OH0620205Medicare PIN
A17563Medicare UPIN