Provider Demographics
NPI:1154305761
Name:WEISSE, MARK OTTO (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:OTTO
Last Name:WEISSE
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 1:5391 MARINERS COVE DR
Mailing Address - Street 2:UNIT 202
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53704-7615
Mailing Address - Country:US
Mailing Address - Phone:608-241-5429
Mailing Address - Fax:
Practice Address - Street 1:115 W DOTY ST
Practice Address - Street 2:PHS MEDICAL OFFICE
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53703-3276
Practice Address - Country:US
Practice Address - Phone:608-284-6071
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI20893207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI20893OtherLICENSE
WI20893OtherLICENSE