Healthcare Provider Details

I. General information

NPI: 1245224633
Provider Name (Legal Business Name): MARK MENTSER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2005
Last Update Date: 11/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 S 18TH ST
COLUMBUS OH
43205-2654
US

IV. Provider business mailing address

555 S 18TH ST
COLUMBUS OH
43205-2654
US

V. Phone/Fax

Practice location:
  • Phone: 614-722-4361
  • Fax: 614-722-6482
Mailing address:
  • Phone: 614-722-4361
  • Fax: 614-722-6482

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0210X
TaxonomyPediatric Nephrology Physician
License Number35042032
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: