Provider Demographics
NPI:1003866864
Name:ROVICK, MARK T (DO)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:T
Last Name:ROVICK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:444 N WESTHILL BLVD
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54914-5715
Mailing Address - Country:US
Mailing Address - Phone:920-750-7000
Mailing Address - Fax:920-364-2451
Practice Address - Street 1:444 N WESTHILL BLVD
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54914-5715
Practice Address - Country:US
Practice Address - Phone:920-750-7000
Practice Address - Fax:920-364-2451
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2017-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI52152-212084P0804X
MN442542084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1003866864Medicaid