Provider Demographics
NPI:1164758314
Name:WERTZ, MARK E (DC)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:E
Last Name:WERTZ
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3105 VILLAGE OFFICE PL
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61822-7673
Mailing Address - Country:US
Mailing Address - Phone:217-352-9108
Mailing Address - Fax:217-352-9105
Practice Address - Street 1:3105 VILLAGE OFFICE PL
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61822-7673
Practice Address - Country:US
Practice Address - Phone:217-352-9108
Practice Address - Fax:217-352-9105
Is Sole Proprietor?:No
Enumeration Date:2009-10-22
Last Update Date:2014-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038011510111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor