Provider Demographics
NPI:1215930946
Name:STACHEL, MARK CARLESS (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:CARLESS
Last Name:STACHEL
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 1:170 W MOHAWK DR
Mailing Address - Street 2:
Mailing Address - City:MALVERN
Mailing Address - State:OH
Mailing Address - Zip Code:44644-9564
Mailing Address - Country:US
Mailing Address - Phone:330-489-1477
Mailing Address - Fax:330-430-6925
Practice Address - Street 1:170 W MOHAWK DR
Practice Address - Street 2:
Practice Address - City:MALVERN
Practice Address - State:OH
Practice Address - Zip Code:44644-9564
Practice Address - Country:US
Practice Address - Phone:330-489-1477
Practice Address - Fax:330-430-6925
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-27
Last Update Date:2020-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35060372207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
1001OtherSUMMA CARE
341684794OtherTAX ID
000000136651OtherBCBS
110050485OtherRR MEDICARE
OH0839874Medicaid
34168479400OtherWC