Provider Demographics
NPI:1356331698
Name:VOLLENWEIDER, MARK ARTHUR (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ARTHUR
Last Name:VOLLENWEIDER
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:PO BOX 919741
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32891-9741
Mailing Address - Country:US
Mailing Address - Phone:218-428-4913
Mailing Address - Fax:321-843-6304
Practice Address - Street 1:1222 S ORANGE AVE
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-1215
Practice Address - Country:US
Practice Address - Phone:321-841-7856
Practice Address - Fax:321-843-6432
Is Sole Proprietor?:No
Enumeration Date:2005-10-27
Last Update Date:2021-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME103507207RC0200X, 207RP1001X
KY39482207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME103507OtherMEDICAL LICENSE
FL000916900Medicaid
FLBY027ZMedicare PIN
KY0366691Medicare ID - Type Unspecified
FLBY027ZMedicare PIN