Provider Demographics
NPI:1821198599
Name:LOOMUS, MARK GEOFFREY (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:GEOFFREY
Last Name:LOOMUS
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 1:1601 BRIGHAM DR
Mailing Address - Street 2:SUITE #150
Mailing Address - City:PERRYSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43551-7114
Mailing Address - Country:US
Mailing Address - Phone:419-872-7482
Mailing Address - Fax:419-872-3754
Practice Address - Street 1:1601 BRIGHAM DR
Practice Address - Street 2:SUITE #150
Practice Address - City:PERRYSBURG
Practice Address - State:OH
Practice Address - Zip Code:43551-7114
Practice Address - Country:US
Practice Address - Phone:419-872-7482
Practice Address - Fax:419-872-3754
Is Sole Proprietor?:No
Enumeration Date:2006-09-23
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010490412084N0400X
OH350596462084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0789928Medicaid
OH0789928Medicaid
OHLO0675106Medicare PIN
OHE56421Medicare UPIN