Provider Demographics
NPI:1134103146
Name:WEBER, MARK A (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:A
Last Name:WEBER
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 1:1000 N OAK AVE
Mailing Address - Street 2:WWP
Mailing Address - City:MARSHFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:54449-5703
Mailing Address - Country:US
Mailing Address - Phone:715-389-0633
Mailing Address - Fax:715-389-0644
Practice Address - Street 1:1700 W STOUT ST
Practice Address - Street 2:
Practice Address - City:RICE LAKE
Practice Address - State:WI
Practice Address - Zip Code:54868-5000
Practice Address - Country:US
Practice Address - Phone:715-234-1515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-02
Last Update Date:2022-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI42203-020207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33338900Medicaid
WI0001-05085Medicare ID - Type UnspecifiedPROVIDER NUMBER
WI0001-05045Medicare ID - Type UnspecifiedPROVIDER NUMBER
WI33338900Medicaid
WI0001-11835Medicare ID - Type UnspecifiedPROVIDER NUMBER