Healthcare Provider Details

I. General information

NPI: 1104870955
Provider Name (Legal Business Name): MARK N CASDORPH D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3130 N COUNTY ROAD 25A
TROY OH
45373-1337
US

IV. Provider business mailing address

3170 KETTERING BLVD BLDG B3
MORAINE OH
45439-1924
US

V. Phone/Fax

Practice location:
  • Phone: 937-440-7305
  • Fax: 937-440-7702
Mailing address:
  • Phone: 937-991-3188
  • Fax: 937-223-9811

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number1322
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number34.007158
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: