Provider Demographics
NPI:1477564003
Name:TOMPKINS, MARK GREGORY (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:GREGORY
Last Name:TOMPKINS
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 1:1000 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46122-1948
Mailing Address - Country:US
Mailing Address - Phone:317-745-4451
Mailing Address - Fax:317-718-6740
Practice Address - Street 1:1000 E MAIN ST
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:IN
Practice Address - Zip Code:46122-1948
Practice Address - Country:US
Practice Address - Phone:317-745-6139
Practice Address - Fax:317-745-7873
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01055570A207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN930126168OtherRAILROAD MEDICARE PIN
IN200409580Medicaid
000000255316OtherANTHEM BLUE SHIELD
000000255316OtherANTHEM BLUE SHIELD
IN200409580Medicaid