Basic Information
Provider Information | |||||||||
NPI: | 1790755924 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JONES | ||||||||
FirstName: | MARK | ||||||||
MiddleName: | A. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 250 N SHADELAND AVE | ||||||||
Address2: | STE 200 | ||||||||
City: | INDIANAPOLIS | ||||||||
State: | IN | ||||||||
PostalCode: | 462194959 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3179632720 | ||||||||
FaxNumber: | 3179624343 | ||||||||
Practice Location | |||||||||
Address1: | 7916 W JEFFERSON BLVD | ||||||||
Address2: |   | ||||||||
City: | FORT WAYNE | ||||||||
State: | IN | ||||||||
PostalCode: | 468044140 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2604322297 | ||||||||
FaxNumber: | 2604346433 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/23/2006 | ||||||||
LastUpdateDate: | 12/27/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/27/2019 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 01025378A | IN | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RA0001X | 01025378A | IN | Y |   |   |   |   |
ID Information
ID | Type | State | Issuer | Description | 000000087412 | 01 | IN | ANTHEM | OTHER | 100054160 | 05 | IN |   | MEDICAID | 0494559 | 05 | OH |   | MEDICAID | P00783715 | 01 |   | RAILROAD | OTHER |