Basic Information
| Provider Information | |||||||||
| NPI: | 1760469233 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PIERCE | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | A. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3702 NEW VISION DR | ||||||||
| Address2: | BLDG B | ||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468451703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2602668210 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2710 LAKE AVE | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468055412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2603738070 | ||||||||
| FaxNumber: | 2603738071 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/27/2005 | ||||||||
| LastUpdateDate: | 03/29/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 01044717A | IN | N | Allopathic & Osteopathic Physicians | Pediatrics | 207R00000X | 01044717A | IN | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200110180 | 05 | IN | MEDICAID | 000000207187 | 01 | IN | ANTHEM | OTHER | 00001719959 07 | 01 | UNITED HEALTHCARE | OTHER | 11041 | 01 | IN | PHYSICIANS HEALTH PLAN | OTHER | 3937240024 | 01 | IN | MEDICARE DMEPOS | OTHER | 7469262 | 01 | AETNA | OTHER | 000000112353 | 01 | IL | ANTHEM | OTHER |