1497724918 NPI number — DR. MARK ANDREW DEWALT DO

Table of content: DR. MARK ANDREW DEWALT DO (NPI 1497724918)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497724918 NPI number — DR. MARK ANDREW DEWALT DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DEWALT
Provider First Name:
MARK
Provider Middle Name:
ANDREW
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DO
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:
1497724918
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/22/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5350 FRANTZ RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DUBLIN
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43016-4259
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4343 ALL SEASONS DR
Provider Second Line Business Practice Location Address:
STE 220
Provider Business Practice Location Address City Name:
HILLIARD
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43026-1961
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
614-544-1100
Provider Business Practice Location Address Fax Number:
614-544-1101
Provider Enumeration Date:
03/16/2006

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: 207Q00000X , with the licence number:  34-008401 , 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: 2637034 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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