Basic Information
| Provider Information | |||||||||
| NPI: | 1346878949 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GJURASHAJ | ||||||||
| FirstName: | MARK | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1132 FAIRVIEW AVE APT H6 | ||||||||
| Address2: | |||||||||
| City: | BOWLING GREEN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421031661 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7278317708 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4461 STATE ROUTE 159 STE A | ||||||||
| Address2: | |||||||||
| City: | CHILLICOTHE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456016000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7407794900 | ||||||||
| FaxNumber: | 7407794909 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2020 | ||||||||
| LastUpdateDate: | 04/04/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.