Provider Demographics
NPI:1518042183
Name:SMUCKLER, MARK B (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:B
Last Name:SMUCKLER
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Gender:M
Credentials:MD
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Mailing Address - Street 1:155 EAST SILVER SPRING DRIVE
Mailing Address - Street 2:203
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53217
Mailing Address - Country:US
Mailing Address - Phone:414-332-2450
Mailing Address - Fax:414-332-1390
Practice Address - Street 1:155 E SILVER SPRING DR
Practice Address - Street 2:203
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53217-4704
Practice Address - Country:US
Practice Address - Phone:414-332-2450
Practice Address - Fax:414-332-1390
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2011-10-11
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Provider Licenses
StateLicense IDTaxonomies
WI161392084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30954800Medicaid
WI30954800Medicaid
WIB56726Medicare UPIN