Healthcare Provider Details

I. General information

NPI: 1255325718
Provider Name (Legal Business Name): MARK R FELDMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2005
Last Update Date: 10/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2551 S SMITH RD
BLOOMINGTON IN
47401-8943
US

IV. Provider business mailing address

2551 S SMITH RD
BLOOMINGTON IN
47401-8943
US

V. Phone/Fax

Practice location:
  • Phone: 812-277-5311
  • Fax:
Mailing address:
  • Phone: 812-277-5311
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number37989
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number01050576A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: