Provider Demographics
NPI:1770573388
Name:MARK, ALEXANDER S (MD)
Entity type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:S
Last Name:MARK
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:PO BOX 1085
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45802-1085
Mailing Address - Country:US
Mailing Address - Phone:844-466-5613
Mailing Address - Fax:419-223-2726
Practice Address - Street 1:3202 TOWER OAKS BLVD
Practice Address - Street 2:UNIT 120
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20852-4219
Practice Address - Country:US
Practice Address - Phone:301-657-2444
Practice Address - Fax:301-657-2450
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-25
Last Update Date:2018-03-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
DEC1-00083392085R0202X
DCMD174722085R0202X
VA01010454312085R0202X
MDD404142085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
000M30C91Medicare PIN
E13450Medicare UPIN
MD022592C10Medicare PIN
MD549712ZA3YMedicare PIN
132005ZAS3Medicare PIN