Provider Demographics
NPI:1306864608
Name:MORONELL, MARK W (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:W
Last Name:MORONELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1380 E STROOP RD
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45429-4926
Mailing Address - Country:US
Mailing Address - Phone:937-293-3486
Mailing Address - Fax:937-293-3605
Practice Address - Street 1:1380 E STROOP RD
Practice Address - Street 2:
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429
Practice Address - Country:US
Practice Address - Phone:937-293-3486
Practice Address - Fax:937-293-3605
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.122658207RC0000X
AK4457207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD1321Medicaid
AK060058886OtherRAILROAD MEDICARE
OH0097860Medicaid
OH0097860Medicaid
OHH252630Medicare PIN
AKK151256Medicare PIN