Provider Demographics
NPI:1942337522
Name:MCNABB, MARK JEFFERY (DO)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:JEFFERY
Last Name:MCNABB
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:3260 LEXINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63701-2609
Mailing Address - Country:US
Mailing Address - Phone:573-335-5057
Mailing Address - Fax:573-335-1552
Practice Address - Street 1:3260 LEXINGTON AVE
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63701-2609
Practice Address - Country:US
Practice Address - Phone:573-335-5057
Practice Address - Fax:573-335-1552
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MODO100129207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO6504OtherANTHEM BLUE CROSS BLUE SH
MO6504OtherANTHEM BLUE CROSS BLUE SH