Provider Demographics
NPI:1063533289
Name:FRADKIN, MARK L (LAC)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:L
Last Name:FRADKIN
Suffix:
Gender:M
Credentials:LAC
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Mailing Address - Street 1:9199 REISTERSTOWN RD
Mailing Address - Street 2:SUITE 211C
Mailing Address - City:OWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117-4520
Mailing Address - Country:US
Mailing Address - Phone:410-363-7254
Mailing Address - Fax:410-363-7254
Practice Address - Street 1:9199 REISTERSTOWN RD
Practice Address - Street 2:SUITE 211C
Practice Address - City:OWINGS MILLS
Practice Address - State:MD
Practice Address - Zip Code:21117-4520
Practice Address - Country:US
Practice Address - Phone:410-363-7254
Practice Address - Fax:410-363-7254
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MDU00323171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDU00323OtherLICENSE