Provider Demographics
NPI:1144548975
Name:DALESANDRO, MARK (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:DALESANDRO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9500 EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44195-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9500 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44195-0001
Practice Address - Country:US
Practice Address - Phone:216-318-8833
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-04
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-396632085R0202X
LA3319582085R0202X
CO580322085R0202X
WAMD605479592085N0700X
NE298212085R0202X
TXR17312085R0202X
TN555442085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NENA2517088OtherMEDICARE PIN
CO559586ZLJ3OtherMEDICARE PIN
CO559586YQ33OtherMEDICARE PIN
CO559586YQN9OtherMEDICARE PIN
CO559586YQPGOtherMEDICARE PIN
KSKA3249088OtherMEDICARE PIN
KS111257097OtherMEDICARE PIN
CO1144548975Medicaid
NENA1214110OtherMEDICARE PIN
CO559586ZNTBOtherMEDICARE PIN
NENA1215111OtherMEDICARE PIN
KS111257097OtherMEDICARE PIN
NENA1214110OtherMEDICARE PIN
KS111257097Medicare PIN
CO559586YQN9Medicare PIN
CO559586ZNTBOtherMEDICARE PIN
CO559586YQN9OtherMEDICARE PIN
CO559586YQ33OtherMEDICARE PIN
CO559586YQPGOtherMEDICARE PIN
CO559586YQ33Medicare PIN