Basic Information
| Provider Information | |||||||||
| NPI: | 1942407135 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JABLONSKI | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | GIRISH | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1675 E MAIN ST | ||||||||
| Address2: | BOX 328 | ||||||||
| City: | KENT | ||||||||
| State: | OH | ||||||||
| PostalCode: | 442405818 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3305931030 | ||||||||
| FaxNumber: | 3306778770 | ||||||||
| Practice Location | |||||||||
| Address1: | 1675 E MAIN ST | ||||||||
| Address2: | BOX 328 | ||||||||
| City: | KENT | ||||||||
| State: | OH | ||||||||
| PostalCode: | 442405818 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3305931030 | ||||||||
| FaxNumber: | 3306778770 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2007 | ||||||||
| LastUpdateDate: | 11/09/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 35.092647 | OH | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 1021420440001 | 05 | PA | MEDICAID | 002061184 | 01 | PA | HIGHMARK | OTHER | 2891545 | 05 | OH | MEDICAID | MD434156 | 01 | PA | MEDICAL LICENSE | OTHER | 35092647 | 01 | OH | MEDICAL LICENSE | OTHER |