Provider Demographics
NPI:1528062932
Name:SMUCKER, MARK L (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:L
Last Name:SMUCKER
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 1:1855 S MAIN ST STE A
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:IN
Mailing Address - Zip Code:46526-4845
Mailing Address - Country:US
Mailing Address - Phone:574-533-7476
Mailing Address - Fax:574-533-7145
Practice Address - Street 1:1855 S MAIN ST STE A
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46526-4845
Practice Address - Country:US
Practice Address - Phone:574-533-7476
Practice Address - Fax:574-533-7145
Is Sole Proprietor?:No
Enumeration Date:2005-06-13
Last Update Date:2014-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01036688A207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100327940Medicaid
IN100327940Medicaid
IN184520RRRMedicare PIN
IN184220GMedicare ID - Type Unspecified