Provider Demographics
NPI:1104870955
Name:CASDORPH, MARK N (DO)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:N
Last Name:CASDORPH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3170 KETTERING BLVD BLDG B3
Mailing Address - Street 2:
Mailing Address - City:MORAINE
Mailing Address - State:OH
Mailing Address - Zip Code:45439-1924
Mailing Address - Country:US
Mailing Address - Phone:937-991-3188
Mailing Address - Fax:937-223-9811
Practice Address - Street 1:3130 N COUNTY ROAD 25A
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:OH
Practice Address - Zip Code:45373-1337
Practice Address - Country:US
Practice Address - Phone:937-440-7305
Practice Address - Fax:937-440-7702
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV13222084P0800X
OH34.0071582084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0004340531OtherAETNA
WV000769253OtherBCBS
WV0005355002Medicaid
WV0115895000Medicaid
WV1045755OtherWORKERS COMPENSATION
WV2132198OtherMAMSI
WVP00281739OtherRAILROAD MEDICARE
WV081465Medicare PIN
WV0005355002Medicaid
WVG40413Medicare UPIN