Provider Demographics
NPI:1063075687
Name:GENDI, MARK WAGIH
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:WAGIH
Last Name:GENDI
Suffix:
Gender:M
Credentials:
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 909
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40201-0909
Mailing Address - Country:US
Mailing Address - Phone:502-588-0328
Mailing Address - Fax:
Practice Address - Street 1:201 ABRAHAM FLEXNER WAY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-3841
Practice Address - Country:US
Practice Address - Phone:502-587-8222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-18
Last Update Date:2024-06-24
Deactivation Date:2019-04-18
Deactivation Code:
Reactivation Date:2019-05-01
Provider Licenses
StateLicense IDTaxonomies
390200000X
KY05886207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX27477312OtherTEXAS DEPARTMENT OF TRANSPORTATION