Provider Demographics
NPI:1952308504
Name:HISKES, MARK RICHARD (DPM)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:RICHARD
Last Name:HISKES
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:69 E GARNER RD
Mailing Address - Street 2:STE 100
Mailing Address - City:BROWNSBURG
Mailing Address - State:IN
Mailing Address - Zip Code:46112-7699
Mailing Address - Country:US
Mailing Address - Phone:317-852-7511
Mailing Address - Fax:317-852-7531
Practice Address - Street 1:69 E GARNER RD
Practice Address - Street 2:STE 100
Practice Address - City:BROWNSBURG
Practice Address - State:IN
Practice Address - Zip Code:46112-7699
Practice Address - Country:US
Practice Address - Phone:317-852-7511
Practice Address - Fax:317-852-7531
Is Sole Proprietor?:No
Enumeration Date:2005-06-28
Last Update Date:2011-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN07000693213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100119070Medicaid
IN1033312020OtherDME
INT93253Medicare UPIN
IN100119070Medicaid