Provider Demographics
NPI:1518904598
Name:HENZLER, MARK A (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:HENZLER
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:2963 E COPPER POINT DR
Mailing Address - Street 2:SUITE 150
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-9055
Mailing Address - Country:US
Mailing Address - Phone:208-322-1730
Mailing Address - Fax:208-322-1731
Practice Address - Street 1:1055 N CURTIS RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-1352
Practice Address - Country:US
Practice Address - Phone:208-322-1730
Practice Address - Fax:208-322-1731
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2015-09-25
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IDM5418207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID003741300Medicaid
IDD93332Medicare UPIN
IDD93332Medicare UPIN