Provider Demographics
NPI:1316942303
Name:STINE, MARK KEVIN (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:KEVIN
Last Name:STINE
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 1:5926 CRAWFORDSVILLE RD B
Mailing Address - Street 2:
Mailing Address - City:SPEEDWAY
Mailing Address - State:IN
Mailing Address - Zip Code:46224-3722
Mailing Address - Country:US
Mailing Address - Phone:317-653-2730
Mailing Address - Fax:
Practice Address - Street 1:163 BUTNER DR
Practice Address - Street 2:
Practice Address - City:HOPE
Practice Address - State:IN
Practice Address - Zip Code:47246-9447
Practice Address - Country:US
Practice Address - Phone:812-546-6000
Practice Address - Fax:812-546-0368
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2019-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01030274A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100330510Medicaid