Provider Demographics
NPI:1851781934
Name:MARK, JULIE P (MD)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:P
Last Name:MARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 N NILES AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-1924
Mailing Address - Country:US
Mailing Address - Phone:574-647-1610
Mailing Address - Fax:
Practice Address - Street 1:1627 E BRISTOL ST
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-3817
Practice Address - Country:US
Practice Address - Phone:574-262-0313
Practice Address - Fax:574-262-8163
Is Sole Proprietor?:No
Enumeration Date:2015-01-28
Last Update Date:2016-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01036572A208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000924711OtherBCBS BMG PEDIATRICS
IN100130050Medicaid
IN236040130Medicare PIN