Provider Demographics
NPI:1841349834
Name:STUBBENDIECK, MARK J (DC)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:J
Last Name:STUBBENDIECK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:780 E SMITH RD # A
Mailing Address - Street 2:
Mailing Address - City:MEDINA
Mailing Address - State:OH
Mailing Address - Zip Code:44256-2662
Mailing Address - Country:US
Mailing Address - Phone:330-725-4060
Mailing Address - Fax:330-722-4582
Practice Address - Street 1:780 E SMITH RD UNIT A
Practice Address - Street 2:
Practice Address - City:MEDINA
Practice Address - State:OH
Practice Address - Zip Code:44256-2662
Practice Address - Country:US
Practice Address - Phone:330-725-4060
Practice Address - Fax:330-722-4582
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1935111NR0400X, 111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No111NR0400XChiropractic ProvidersChiropractorRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000138771OtherANTHEM BLUE CROSS
OH2657665Medicaid
OH000000138771OtherANTHEM BLUE CROSS