Provider Demographics
NPI:1477598522
Name:ENDERLE, MARK ALFRED (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ALFRED
Last Name:ENDERLE
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 1:620 HIGHLEADON PL
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-7655
Mailing Address - Country:US
Mailing Address - Phone:601-421-3671
Mailing Address - Fax:
Practice Address - Street 1:1600 E WOODROW WILSON AVE
Practice Address - Street 2:THIRD FLOOR SUITE A
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-5100
Practice Address - Country:US
Practice Address - Phone:601-364-7861
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARN-6348207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARB-90165Medicare UPIN