Healthcare Provider Details

I. General information

NPI: 1760115125
Provider Name (Legal Business Name): DOUGLAS MICHAEL MARKS PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/05/2022
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 MARY ST
EVANSVILLE IN
47710-1658
US

IV. Provider business mailing address

600 MARY ST
EVANSVILLE IN
47710-1658
US

V. Phone/Fax

Practice location:
  • Phone: 812-450-3405
  • Fax:
Mailing address:
  • Phone: 812-450-3405
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10005118A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: