Provider Demographics
NPI:1013053503
Name:WILLARD, MARK ALLEN (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ALLEN
Last Name:WILLARD
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 1:6480 HARRISON AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45247-7961
Mailing Address - Country:US
Mailing Address - Phone:614-221-3725
Mailing Address - Fax:614-221-5613
Practice Address - Street 1:7277 SMITHS MILL RD
Practice Address - Street 2:SUITE#250
Practice Address - City:NEW ALBANY
Practice Address - State:OH
Practice Address - Zip Code:43054-8195
Practice Address - Country:US
Practice Address - Phone:614-221-3725
Practice Address - Fax:614-221-5613
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2023-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35080144207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2285129Medicaid
OHWI4060321Medicare ID - Type Unspecified
OH2285129Medicaid