Provider Demographics
NPI:1881673614
Name:TERELETSKY, MARK J (DO)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:J
Last Name:TERELETSKY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:323 MARION AVE NW
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MASSILLON
Mailing Address - State:OH
Mailing Address - Zip Code:44646-3639
Mailing Address - Country:US
Mailing Address - Phone:330-837-1111
Mailing Address - Fax:330-837-1769
Practice Address - Street 1:830 S MAIN ST
Practice Address - Street 2:
Practice Address - City:ORRVILLE
Practice Address - State:OH
Practice Address - Zip Code:44667-2291
Practice Address - Country:US
Practice Address - Phone:330-684-1300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-11
Last Update Date:2010-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34-004475207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0686057Medicaid
OHA17268Medicare UPIN
OH0686057Medicaid