Provider Demographics
NPI:1124715073
Name:CHESEBRO, MARK ANTHONY JR (DO)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:ANTHONY
Last Name:CHESEBRO
Suffix:JR
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:LAKELAND HEALTH-GME 1234 NAPIER AVENUE
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085
Mailing Address - Country:US
Mailing Address - Phone:269-982-4941
Mailing Address - Fax:
Practice Address - Street 1:LAKELAND HEALTH-GME 1234 NAPIER AVENUE
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085
Practice Address - Country:US
Practice Address - Phone:269-982-4941
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-20
Last Update Date:2023-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI390200000X
MI5151016213207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program