Healthcare Provider Details

I. General information

NPI: 1508802273
Provider Name (Legal Business Name): MARK A TRUAX MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2006
Last Update Date: 04/15/2021
Certification Date: 04/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 N LEBANON ST
JAMESTOWN IN
46147-9372
US

IV. Provider business mailing address

2705 N LEBANON ST STE 305
LEBANON IN
46052-8622
US

V. Phone/Fax

Practice location:
  • Phone: 765-676-5754
  • Fax: 765-676-9853
Mailing address:
  • Phone: 765-485-8852
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01032015
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01032015A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: