Healthcare Provider Details

I. General information

NPI: 1447220843
Provider Name (Legal Business Name): MARK DOUGLAS FOX MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2006
Last Update Date: 10/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1234 N NOTRE DAME AVE
SOUTH BEND IN
46617-1404
US

IV. Provider business mailing address

1234 N NOTRE DAME AVE
SOUTH BEND IN
46617-1404
US

V. Phone/Fax

Practice location:
  • Phone: 574-631-1337
  • Fax: 574-631-8932
Mailing address:
  • Phone: 574-631-1337
  • Fax: 574-631-8932

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number23209
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number01075847A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number23209
License Number StateOK
# 4
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number01075847A
License Number StateIN
# 5
Primary TaxonomyY
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number01075847A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: