Provider Demographics
NPI:1295183580
Name:DODGE, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:DODGE
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:N1945 SHORE DR
Mailing Address - Street 2:
Mailing Address - City:MARINETTE
Mailing Address - State:WI
Mailing Address - Zip Code:54143-9213
Mailing Address - Country:US
Mailing Address - Phone:715-732-0148
Mailing Address - Fax:
Practice Address - Street 1:701 WILLOW ST
Practice Address - Street 2:
Practice Address - City:PESHTIGO
Practice Address - State:WI
Practice Address - Zip Code:54157-1165
Practice Address - Country:US
Practice Address - Phone:715-582-0144
Practice Address - Fax:715-582-0803
Is Sole Proprietor?:No
Enumeration Date:2016-05-27
Last Update Date:2016-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2053225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant