Provider Demographics
NPI:1194503193
Name:WHITACRE, MARK THOMAS
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:THOMAS
Last Name:WHITACRE
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 1:308 MARTINSBURG RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:OH
Mailing Address - Zip Code:43050-4225
Mailing Address - Country:US
Mailing Address - Phone:740-393-6767
Mailing Address - Fax:
Practice Address - Street 1:308 MARTINSBURG RD
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:OH
Practice Address - Zip Code:43050-4225
Practice Address - Country:US
Practice Address - Phone:740-393-6767
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-20
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3462225XP0019X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation