Provider Demographics
NPI:1770587339
Name:MARK, DAVID G (MD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:G
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 1:10466 WOODCHUCK CT
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-6029
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:17501 GENERATIONS DR
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46635-1589
Practice Address - Country:US
Practice Address - Phone:574-000-0000
Practice Address - Fax:574-000-0000
Is Sole Proprietor?:No
Enumeration Date:2005-06-10
Last Update Date:2016-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01037623A207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN2004184004OtherCIGNA
IN000000084424OtherBLUECROSS BLUESHIELD
IN4229217OtherAETNA
IN100323890AMedicaid
IN110082367OtherRAIL ROAD MEDICARE
IN000000084424OtherBLUECROSS BLUESHIELD
IN110082367OtherRAIL ROAD MEDICARE