Provider Demographics
NPI:1083637524
Name:WALTERSKIRCHEN, MARK J (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:J
Last Name:WALTERSKIRCHEN
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:PO BOX 2580
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65801-2580
Mailing Address - Country:US
Mailing Address - Phone:417-829-4620
Mailing Address - Fax:417-829-4316
Practice Address - Street 1:1965 S FREMONT AVE
Practice Address - Street 2:SUITE 370
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-2201
Practice Address - Country:US
Practice Address - Phone:417-820-0300
Practice Address - Fax:417-882-9645
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2012-09-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WAMD00048487208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO340017773OtherRR MEDICARE PROV. #
MO1083637524OtherNPI #
MO204964605Medicaid
MO105013268Medicare PIN
MO132300100Medicare PIN
MO1083637524OtherNPI #