Healthcare Provider Details

I. General information

NPI: 1831654680
Provider Name (Legal Business Name): MARK ESIYEDEN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2019
Last Update Date: 02/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1407 1/2 CHICAGO STREET 4
VALPARAISO IN
46383
US

IV. Provider business mailing address

1407 1/2 CHICAGO STREET 4
VALPARAISO IN
46383
US

V. Phone/Fax

Practice location:
  • Phone: 219-707-3767
  • Fax:
Mailing address:
  • Phone: 219-707-3767
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code344600000X
TaxonomyTaxi
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code172A00000X
TaxonomyDriver
License Number4420277588
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: