Healthcare Provider Details

I. General information

NPI: 1942211313
Provider Name (Legal Business Name): MARK D PESCOVITZ X M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2006
Last Update Date: 08/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 UNIVERSITY BLVD. #UH 4601
INDIANAPOLIS IN
46202
US

IV. Provider business mailing address

550 UNIVERSITY BLVD. #UH 4601
INDIANAPOLIS IN
46202
US

V. Phone/Fax

Practice location:
  • Phone: 317-274-4370
  • Fax: 317-278-3268
Mailing address:
  • Phone: 317-274-4370
  • Fax: 317-278-3268

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204F00000X
TaxonomyTransplant Surgery Physician
License Number01036924A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: