Provider Demographics
NPI:1679739163
Name:MARK, LAQUISHA S (MD)
Entity type:Individual
Prefix:
First Name:LAQUISHA
Middle Name:S
Last Name:MARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:529 CRAWLEY RUN
Mailing Address - Street 2:APT. #208
Mailing Address - City:CENTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45458-6396
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2345 PHILADELPHIA DR
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45406-1816
Practice Address - Country:US
Practice Address - Phone:937-276-4141
Practice Address - Fax:937-277-7249
Is Sole Proprietor?:No
Enumeration Date:2008-08-04
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH57-014699390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program