Provider Demographics
NPI:1831191485
Name:MISHACK, MARK (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:MISHACK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:15945 19 MILE RD
Mailing Address - Street 2:STE 104
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-1147
Mailing Address - Country:US
Mailing Address - Phone:586-228-6603
Mailing Address - Fax:586-228-6613
Practice Address - Street 1:15945 19 MILE RD
Practice Address - Street 2:STE 104
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48038-1147
Practice Address - Country:US
Practice Address - Phone:586-228-6603
Practice Address - Fax:586-228-6613
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-12
Last Update Date:2009-09-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MIMM062491207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
G94558Medicare UPIN