Provider Demographics
NPI:1083776736
Name:FENLON, MARK F (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:F
Last Name:FENLON
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 1:900 ILLINOIS AVENUE
Mailing Address - Street 2:
Mailing Address - City:STEVENS POINT
Mailing Address - State:WI
Mailing Address - Zip Code:54481
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2401 PLOVER ROAD
Practice Address - Street 2:
Practice Address - City:PLOVER
Practice Address - State:WI
Practice Address - Zip Code:54467
Practice Address - Country:US
Practice Address - Phone:715-259-3800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2008-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI26785207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30689500Medicaid
WI30689500Medicaid