Provider Demographics
NPI:1881765931
Name:DUCKWALL, MARK G (DC)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:G
Last Name:DUCKWALL
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:233 CORRY ST
Mailing Address - Street 2:
Mailing Address - City:YELLOW SPRINGS
Mailing Address - State:OH
Mailing Address - Zip Code:45387
Mailing Address - Country:US
Mailing Address - Phone:937-767-7251
Mailing Address - Fax:937-767-7252
Practice Address - Street 1:233 CORRY ST
Practice Address - Street 2:
Practice Address - City:YELLOW SPRINGS
Practice Address - State:OH
Practice Address - Zip Code:45387
Practice Address - Country:US
Practice Address - Phone:937-767-7251
Practice Address - Fax:937-767-7252
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-12
Last Update Date:2010-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH642111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHDU0445551Medicare ID - Type Unspecified