Provider Demographics
NPI:1497984983
Name:VOGEL, MARK W (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:W
Last Name:VOGEL
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 1:625 S NEW BALLAS RD
Mailing Address - Street 2:SUITE 2030
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8253
Mailing Address - Country:US
Mailing Address - Phone:314-251-1700
Mailing Address - Fax:
Practice Address - Street 1:625 S NEW BALLAS RD
Practice Address - Street 2:SUITE 2030
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8253
Practice Address - Country:US
Practice Address - Phone:314-251-1700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-07
Last Update Date:2015-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MN53224207R00000X
MO2012011193207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNENROLLEDMedicaid
MNENROLLEDMedicaid