Healthcare Provider Details

I. General information

NPI: 1124715073
Provider Name (Legal Business Name): MARK ANTHONY CHESEBRO JR. D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2023
Last Update Date: 06/24/2026
Certification Date: 06/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11109 PARKVIEW PLAZA DR
FORT WAYNE IN
46845-1701
US

IV. Provider business mailing address

608 UNION CHAPEL RD
FORT WAYNE IN
46845-9357
US

V. Phone/Fax

Practice location:
  • Phone: 260-482-4440
  • Fax:
Mailing address:
  • Phone: 269-982-4941
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number5151016213
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number02008912A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: