Healthcare Provider Details

I. General information

NPI: 1770587339
Provider Name (Legal Business Name): DAVID G MARK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2005
Last Update Date: 05/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17501 GENERATIONS DR
SOUTH BEND IN
46635-1589
US

IV. Provider business mailing address

10466 WOODCHUCK CT
GRANGER IN
46530-6029
US

V. Phone/Fax

Practice location:
  • Phone: 574-000-0000
  • Fax: 574-000-0000
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number01037623A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: