Provider Demographics
NPI:1740230739
Name:HACKMAN, MARK A (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:HACKMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:5969 EAST BROAD STREET
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43213
Mailing Address - Country:US
Mailing Address - Phone:614-864-6010
Mailing Address - Fax:614-864-0306
Practice Address - Street 1:5969 EAST BROAD STREET
Practice Address - Street 2:2ND FLOOR
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43213
Practice Address - Country:US
Practice Address - Phone:614-864-6010
Practice Address - Fax:614-864-0306
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH35049129H207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0454119Medicaid
OH0454119Medicaid
OHCA9180583Medicare ID - Type Unspecified