Provider Demographics
NPI:1558443010
Name:WASOWSKI, MARK J (DC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:J
Last Name:WASOWSKI
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 787
Mailing Address - Street 2:
Mailing Address - City:WINDHAM
Mailing Address - State:ME
Mailing Address - Zip Code:04062-0787
Mailing Address - Country:US
Mailing Address - Phone:207-892-9001
Mailing Address - Fax:207-892-3228
Practice Address - Street 1:584 ROOSEVELT TRL
Practice Address - Street 2:
Practice Address - City:WINDHAM
Practice Address - State:ME
Practice Address - Zip Code:04062-7302
Practice Address - Country:US
Practice Address - Phone:207-892-9001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2015-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECR646111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME258210099Medicaid
8413254OtherCIGNA
5867646OtherAETNA
5867646OtherAETNA
ME258210099Medicaid