Healthcare Provider Details

I. General information

NPI: 1801980784
Provider Name (Legal Business Name): MARK BIDWELL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 07/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3533 SOUTHERN BLVD SUITE 4100
KETTERING OH
45429-1264
US

IV. Provider business mailing address

1 PRESTIGE PL SUITE 550
MIAMISBURG OH
45342-3794
US

V. Phone/Fax

Practice location:
  • Phone: 937-395-8444
  • Fax: 937-395-8450
Mailing address:
  • Phone: 937-752-2305
  • Fax: 937-522-7513

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VE0102X
TaxonomyReproductive Endocrinology Physician
License Number35052666
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: