Healthcare Provider Details

I. General information

NPI: 1093715062
Provider Name (Legal Business Name): MARK A JENSEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2005
Last Update Date: 08/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2217 DUBOIS DR
WARSAW IN
46580-3212
US

IV. Provider business mailing address

2217 DUBOIS DR
WARSAW IN
46580-3212
US

V. Phone/Fax

Practice location:
  • Phone: 574-267-8940
  • Fax: 574-267-5782
Mailing address:
  • Phone: 574-267-8940
  • Fax: 574-267-5782

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number01033577
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number01033577
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: