Provider Demographics
NPI:1801842422
Name:OGLE, MARK ROBERT (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ROBERT
Last Name:OGLE
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 1:9310 WALDEMAR RD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-1134
Mailing Address - Country:US
Mailing Address - Phone:317-897-1303
Mailing Address - Fax:
Practice Address - Street 1:9310 WALDEMAR RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46268-1134
Practice Address - Country:US
Practice Address - Phone:317-879-1303
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2019-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ININ01036907A2084P0800X, 2084P0805X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100132300Medicaid
IN338450Medicare PIN
IND95680Medicare UPIN
IN165490HHHMedicare PIN
INM400027800Medicare PIN