Provider Demographics
NPI:1881782936
Name:MARK, MATTHEW (MD)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
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 901666
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44190-1666
Mailing Address - Country:US
Mailing Address - Phone:440-232-5400
Mailing Address - Fax:440-232-0084
Practice Address - Street 1:50 BLAINE AVE STE 2200
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:OH
Practice Address - Zip Code:44146-2709
Practice Address - Country:US
Practice Address - Phone:440-232-5400
Practice Address - Fax:440-232-0084
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2021-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35075459M207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2191097Medicaid
OH4026332Medicare PIN