Provider Demographics
NPI:1841300761
Name:ENTRUP, MARK H (DO)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:H
Last Name:ENTRUP
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 4046
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65808-4046
Mailing Address - Country:US
Mailing Address - Phone:417-269-5712
Mailing Address - Fax:417-269-7567
Practice Address - Street 1:3801 S NATIONAL AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-5210
Practice Address - Country:US
Practice Address - Phone:417-269-7728
Practice Address - Fax:417-269-7729
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2020-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO100131207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
10066OtherBLUE CROSS MO
MO246655427Medicaid
MO246655427Medicaid
P00384528Medicare PIN
963405125Medicare PIN
110087183Medicare PIN
000005527Medicare PIN
110157897Medicare PIN
003013519Medicare PIN