Provider Demographics
NPI:1326037219
Name:MARK, ROGER GREENWOOD (MD)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:GREENWOOD
Last Name:MARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:70 PACIFIC ST
Mailing Address - Street 2:APT 568
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02139-4204
Mailing Address - Country:US
Mailing Address - Phone:617-253-0378
Mailing Address - Fax:
Practice Address - Street 1:545A CENTRE ST
Practice Address - Street 2:
Practice Address - City:JAMAICA PLAIN
Practice Address - State:MA
Practice Address - Zip Code:02130-2061
Practice Address - Country:US
Practice Address - Phone:617-522-5464
Practice Address - Fax:617-524-2966
Is Sole Proprietor?:No
Enumeration Date:2005-10-14
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA29758207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0155578Medicaid
MAM07604Medicare PIN
MA0155578Medicaid