Provider Demographics
NPI:1093805251
Name:NEUENSCHWANDER, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:NEUENSCHWANDER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5515 NW CACHE RD
Mailing Address - Street 2:APT D4
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-3345
Mailing Address - Country:US
Mailing Address - Phone:580-458-2225
Mailing Address - Fax:
Practice Address - Street 1:12647 OLIVE BLVD
Practice Address - Street 2:SUITE 600
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-6345
Practice Address - Country:US
Practice Address - Phone:800-325-3982
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK12565207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine