Provider Demographics
NPI:1780754127
Name:AUSTIN, MARK (DO)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:AUSTIN
Suffix:
Gender:M
Credentials:DO
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 1105
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-1105
Mailing Address - Country:US
Mailing Address - Phone:618-457-5200
Mailing Address - Fax:618-529-0568
Practice Address - Street 1:500 LINCOLN DR STE D
Practice Address - Street 2:
Practice Address - City:HERRIN
Practice Address - State:IL
Practice Address - Zip Code:62948-6355
Practice Address - Country:US
Practice Address - Phone:618-457-5200
Practice Address - Fax:618-529-0568
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2011-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360798782083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
E64737Medicare UPIN
IL214881Medicare Oscar/Certification