Provider Demographics
NPI:1457312894
Name:MARK, MARTIN D (MD)
Entity type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:D
Last Name:MARK
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:PO BOX 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:3999 DUTCHMANS LN
Practice Address - Street 2:SUITE 7B
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4729
Practice Address - Country:US
Practice Address - Phone:502-896-4711
Practice Address - Fax:502-896-4791
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2016-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY29138174400000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000049919OtherANTHEM PIN #
KY64291388Medicaid
IN201083450Medicaid
KY50034544OtherPASSPORT- NORTON SURGICAL SPECIALISTS
KY253902Medicare ID - Type Unspecified
KY50034544OtherPASSPORT- NORTON SURGICAL SPECIALISTS
KYB98101Medicare UPIN