1407849516 NPI number — MARK D POPHAL M.D.

Table of content: MARK D POPHAL M.D. (NPI 1407849516)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407849516 NPI number — MARK D POPHAL M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
POPHAL
Provider First Name:
MARK
Provider Middle Name:
D
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1407849516
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 378
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SANDUSKY
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44871-0378
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
419-626-6161
Provider Business Mailing Address Fax Number:
419-502-3511

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
29001 CEDAR RD STE 110
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LYNDHURST
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44124-4041
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
216-382-8022
Provider Business Practice Location Address Fax Number:
216-382-7667
Provider Enumeration Date:
08/24/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X , with the licence number:  35-05-9490-P , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 180028844 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1193810001 . This is a "DMERC MEDICARE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 34-1844400 . This is a "TAX ID#" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 2027612 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: H140671 . This is a "MEDICARE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com