Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207SG0201X | Clinical Genetics (M.D.) | 4301057958 | MI |
N | 207V00000X | Obstetrician & Gynecologist | 01040767A | IN |
NPI | 1831137629 |
---|---|
Provider Name | Dr. Paul Mark |
First Address | Grand Rapids, MI 49503-2560 |
Second Address | Grand Rapids, MI 49503-2515 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/06/2006 |
Last Update Date | 26/02/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1831137629 | (05) | MI |
200056530A | (05) | IN |
F43665 | (02) | IN |