Healthcare Provider Details

I. General information

NPI: 1578567426
Provider Name (Legal Business Name): JOHN MARK MICHAEL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2005
Last Update Date: 03/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

242 WILLOWGATE LN
INDIANAPOLIS IN
46260-1431
US

IV. Provider business mailing address

242 WILLOWGATE LN
INDIANAPOLIS IN
46260-1431
US

V. Phone/Fax

Practice location:
  • Phone: 317-848-1611
  • Fax:
Mailing address:
  • Phone: 317-848-1611
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number01033505
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: