Provider Demographics
NPI:1922096817
Name:HORATTAS, MARK C (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:C
Last Name:HORATTAS
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 1:400 WABASH AVE
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44307-2433
Mailing Address - Country:US
Mailing Address - Phone:330-344-6699
Mailing Address - Fax:330-344-6959
Practice Address - Street 1:400 WABASH AVE
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44307-2433
Practice Address - Country:US
Practice Address - Phone:330-344-6699
Practice Address - Fax:330-344-6959
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-13
Last Update Date:2011-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35053968174400000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0784469Medicaid
OHE54251Medicare UPIN