Provider Demographics
NPI:1780655381
Name:MARK, JEFFERY A (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFERY
Middle Name:A
Last Name:MARK
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 1:515 S 2ND ST
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46516-3224
Mailing Address - Country:US
Mailing Address - Phone:574-295-4141
Mailing Address - Fax:
Practice Address - Street 1:515 S 2ND ST
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46516-3224
Practice Address - Country:US
Practice Address - Phone:574-295-4141
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-31
Last Update Date:2011-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01039223A208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100114070BMedicaid
IN100114070BMedicaid
IN182970Medicare ID - Type Unspecified