Provider Demographics
NPI:1053498782
Name:MARK, WILLIAM W JR (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:W
Last Name:MARK
Suffix:JR
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 1:224 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:MD
Mailing Address - Zip Code:21502-2827
Mailing Address - Country:US
Mailing Address - Phone:301-777-8383
Mailing Address - Fax:301-777-2780
Practice Address - Street 1:224 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:CUMBERLAND
Practice Address - State:MD
Practice Address - Zip Code:21502-2827
Practice Address - Country:US
Practice Address - Phone:301-777-8383
Practice Address - Fax:301-777-2780
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2012-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD31221174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD356351100Medicaid
MDD75298Medicare UPIN
MD173L 077BMedicare ID - Type Unspecified