Healthcare Provider Details

I. General information

NPI: 1952308504
Provider Name (Legal Business Name): MARK RICHARD HISKES DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2005
Last Update Date: 11/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

69 E GARNER RD STE 100
BROWNSBURG IN
46112-7699
US

IV. Provider business mailing address

69 E GARNER RD STE 100
BROWNSBURG IN
46112-7699
US

V. Phone/Fax

Practice location:
  • Phone: 317-852-7511
  • Fax: 317-852-7531
Mailing address:
  • Phone: 317-852-7511
  • Fax: 317-852-7531

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number07000693
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: