Provider Demographics
NPI:1003930124
Name:WILLENBRING, MARK LEON (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:LEON
Last Name:WILLENBRING
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:745 VICTORIA ST S
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55102-4203
Mailing Address - Country:US
Mailing Address - Phone:202-379-6736
Mailing Address - Fax:
Practice Address - Street 1:745 VICTORIA ST S
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-4203
Practice Address - Country:US
Practice Address - Phone:202-379-6736
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-16
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN220402084F0202X, 2084P0802X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084F0202XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyForensic Psychiatry
No2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC037919700Medicaid
DC037919700Medicaid
DC019317M83Medicare ID - Type Unspecified