Provider Demographics
NPI:1902875123
Name:HERBERT, MARK THOMAS (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:THOMAS
Last Name:HERBERT
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 1:775 W BROAD ST STE 200
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43222-1471
Mailing Address - Country:US
Mailing Address - Phone:614-627-1610
Mailing Address - Fax:614-228-5040
Practice Address - Street 1:775 W BROAD ST STE 200
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43222-1471
Practice Address - Country:US
Practice Address - Phone:614-627-1610
Practice Address - Fax:614-228-5040
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2025-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35053795207R00000X
OH35053795H207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0788741Medicaid
OH0669654Medicare PIN
E54291Medicare UPIN