Provider Demographics
NPI:1740282490
Name:CIMINO, MARK ALLEN (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:ALLEN
Last Name:CIMINO
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 1:1111 HOMER RD
Mailing Address - Street 2:
Mailing Address - City:MINDEN
Mailing Address - State:LA
Mailing Address - Zip Code:71055-3027
Mailing Address - Country:US
Mailing Address - Phone:318-377-7500
Mailing Address - Fax:318-377-2324
Practice Address - Street 1:1111 HOMER RD
Practice Address - Street 2:
Practice Address - City:MINDEN
Practice Address - State:LA
Practice Address - Zip Code:71055-3027
Practice Address - Country:US
Practice Address - Phone:318-377-7500
Practice Address - Fax:318-377-2324
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-12
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA15018R207Q00000X
ARE3519207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1422878Medicaid
LALA15018ROtherSTATE MEDICAL LICENSE
LA030637OtherLA NARCOTIC LICENSE
AR1422878Medicaid
LABC8097099OtherFEDERAL DEA NUMBER
LA4F388Medicare PIN
AR1740282490Medicare PIN
AR1422878Medicaid