Provider Demographics
NPI:1134129398
Name:FLANZENBAUM, MARK A (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:A
Last Name:FLANZENBAUM
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 1:5021 CRAIG RATH BLVD BLDG 4
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23112-6243
Mailing Address - Country:US
Mailing Address - Phone:804-592-5437
Mailing Address - Fax:804-474-9071
Practice Address - Street 1:5021 CRAIG RATH BLVD BLDG 4
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23112-6243
Practice Address - Country:US
Practice Address - Phone:804-592-5437
Practice Address - Fax:804-474-9071
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2014-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101047168208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA5859433Medicaid
VA5859433Medicaid