Provider Demographics
NPI:1326013327
Name:LITZ, MARK A (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:LITZ
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 1:250 N SHADELAND AVE
Mailing Address - Street 2:STE 130 ATTN SHAKILA GERMANY
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:317-962-4792
Mailing Address - Fax:317-962-4343
Practice Address - Street 1:1420 S. PILGRIM BLVD.
Practice Address - Street 2:
Practice Address - City:YORKTOWN
Practice Address - State:IN
Practice Address - Zip Code:47396-9250
Practice Address - Country:US
Practice Address - Phone:765-759-4068
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2014-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01053704A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP00936176OtherRR MEDICARE
IN200356770Medicaid
IN194590011Medicare PIN
INM400022666Medicare PIN
INH47643Medicare UPIN