Provider Demographics
NPI:1942211313
Name:PESCOVITZ, MARK D X (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:D
Last Name:PESCOVITZ
Suffix:X
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 1:550 UNIVERSITY BLVD. #UH 4601
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202
Mailing Address - Country:US
Mailing Address - Phone:317-274-4370
Mailing Address - Fax:317-278-3268
Practice Address - Street 1:550 UNIVERSITY BLVD. #UH 4601
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202
Practice Address - Country:US
Practice Address - Phone:317-274-4370
Practice Address - Fax:317-278-3268
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2010-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01036924A204F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204F00000XAllopathic & Osteopathic PhysiciansTransplant Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200002680AMedicaid
IND46983Medicare UPIN
IN200002680AMedicaid