Provider Demographics
NPI:1831654680
Name:ESIYEDEN, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:ESIYEDEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1407 1/2 CHICAGO STREET
Mailing Address - Street 2:4
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46383
Mailing Address - Country:US
Mailing Address - Phone:219-707-3767
Mailing Address - Fax:
Practice Address - Street 1:1407 1/2 CHICAGO STREET
Practice Address - Street 2:4
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383
Practice Address - Country:US
Practice Address - Phone:219-707-3767
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-06
Last Update Date:2019-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN4420277588172A00000X
344600000X, 343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No172A00000XOther Service ProvidersDriver
No344600000XTransportation ServicesTaxi
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN4420277588OtherDRIVERS LICENCE