Provider Demographics
NPI:1457065344
Name:ELIZONDO, MARK (MS, LAT, ATC)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:ELIZONDO
Suffix:
Gender:M
Credentials:MS, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 W WABASH AVE STE A
Mailing Address - Street 2:
Mailing Address - City:CRAWFORDSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47933-2484
Mailing Address - Country:US
Mailing Address - Phone:765-361-6235
Mailing Address - Fax:
Practice Address - Street 1:301 W WABASH AVE STE A
Practice Address - Street 2:
Practice Address - City:CRAWFORDSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47933-2484
Practice Address - Country:US
Practice Address - Phone:765-361-6235
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-06
Last Update Date:2023-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36000944A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
080202029OtherNATIONAL ATHLETIC TRAINERS ASSOCIATION