Provider Demographics
NPI:1265532212
Name:O'BRIEN, MARK D (DO)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:D
Last Name:O'BRIEN
Suffix:
Gender:
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6507 E STATE BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46815-7026
Practice Address - Country:US
Practice Address - Phone:260-486-3300
Practice Address - Fax:260-486-3600
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2025-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02001451A208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000606296OtherANTHEM
IN200931380Medicaid
IN069860TTTTMedicare PIN