Provider Demographics
NPI:1477675635
Name:WARNER, MARK (DO)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:WARNER
Suffix:
Gender:M
Credentials:DO
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Mailing Address - Street 1:5030 STATE ROAD
Mailing Address - Street 2:STE 2-900
Mailing Address - City:DREXEL HILL
Mailing Address - State:PA
Mailing Address - Zip Code:19026-4653
Mailing Address - Country:US
Mailing Address - Phone:610-623-9080
Mailing Address - Fax:610-623-3861
Practice Address - Street 1:5030 STATE ROAD
Practice Address - Street 2:STE 2-900
Practice Address - City:DREXEL HILL
Practice Address - State:PA
Practice Address - Zip Code:19026-4653
Practice Address - Country:US
Practice Address - Phone:610-623-9080
Practice Address - Fax:610-623-3861
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAOS005359L208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0010979340002Medicaid
PA0010979340002Medicaid