Provider Demographics
NPI:1780819466
Name:LOBO, MARK JOHN
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:JOHN
Last Name:LOBO
Suffix:
Gender:M
Credentials:
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 4699
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47903-4699
Mailing Address - Country:US
Mailing Address - Phone:765-449-2732
Mailing Address - Fax:765-449-1196
Practice Address - Street 1:1425 UNITY PL
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-5756
Practice Address - Country:US
Practice Address - Phone:765-447-7460
Practice Address - Fax:765-447-8396
Is Sole Proprietor?:No
Enumeration Date:2009-05-25
Last Update Date:2014-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN0102085R0001X, 2085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201180380Medicaid
IN000000829823OtherANTHEM
IN000000837944OtherANTHEM
IN5023973OtherAETNA
IN201180380Medicaid
IN6777300009Medicare PIN