Provider Demographics
NPI:1083608848
Name:FAUSTICH, MARK W (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:W
Last Name:FAUSTICH
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 1:1531 S MADISON ST
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54915-1800
Mailing Address - Country:US
Mailing Address - Phone:920-730-4413
Mailing Address - Fax:
Practice Address - Street 1:1531 S MADISON ST
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54915-1800
Practice Address - Country:US
Practice Address - Phone:920-730-4413
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-08
Last Update Date:2008-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI27201207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30732500Medicaid
WI30732500Medicaid
WI015071018Medicare PIN
WI001745300Medicare PIN