Provider Demographics
NPI:1649459520
Name:ALLEN, MARK DALE (DC,)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:DALE
Last Name:ALLEN
Suffix:
Gender:M
Credentials:DC,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1809 E 10TH ST
Mailing Address - Street 2:
Mailing Address - City:JEFFERSONVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47130-6015
Mailing Address - Country:US
Mailing Address - Phone:812-282-8977
Mailing Address - Fax:
Practice Address - Street 1:1809 E 10TH ST
Practice Address - Street 2:
Practice Address - City:JEFFERSONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47130-6015
Practice Address - Country:US
Practice Address - Phone:812-282-8977
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-29
Last Update Date:2007-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08001031A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1184842882OtherGROUP NPI
IN000000042506OtherANTHEM
IN1184842882OtherGROUP NPI
INU02646Medicare UPIN