Provider Demographics
NPI:1003342866
Name:EHLERS, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:EHLERS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2801 W KINNICKINNIC RIVER PKWY STE 330
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-3669
Mailing Address - Country:US
Mailing Address - Phone:414-649-1280
Mailing Address - Fax:414-649-1288
Practice Address - Street 1:2801 W KINNICKINNIC RIVER PKWY STE 330
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215-3669
Practice Address - Country:US
Practice Address - Phone:414-649-1280
Practice Address - Fax:414-649-1288
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-11
Last Update Date:2022-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI77320208800000X, 208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1003342866Medicaid