Provider Demographics
NPI:1447257506
Name:DESILVIO, MARK S (DPM)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:S
Last Name:DESILVIO
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:735 HASKINS RD
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:OH
Mailing Address - Zip Code:43402-1638
Mailing Address - Country:US
Mailing Address - Phone:419-352-8110
Mailing Address - Fax:419-354-1425
Practice Address - Street 1:735 HASKINS RD
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:OH
Practice Address - Zip Code:43402-1638
Practice Address - Country:US
Practice Address - Phone:419-352-8110
Practice Address - Fax:419-354-1425
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36001882D213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0408991Medicaid
T80470Medicare UPIN
DEO463662Medicare ID - Type Unspecified