Provider Demographics
NPI:1124052212
Name:BOETTLER, MARK ARDEN (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:ARDEN
Last Name:BOETTLER
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6136 OLD SPANISH TRL
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45459-1453
Mailing Address - Country:US
Mailing Address - Phone:937-428-0652
Mailing Address - Fax:
Practice Address - Street 1:8100 N MAIN ST
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45415-1702
Practice Address - Country:US
Practice Address - Phone:937-974-0652
Practice Address - Fax:937-372-1254
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2025-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35057004207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHE76482Medicare UPIN