Provider Demographics
NPI:1619903556
Name:MENENDEZ, MARK M (DPM)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:M
Last Name:MENENDEZ
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:211 EXECUTIVE DR STE 11
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19702-3358
Mailing Address - Country:US
Mailing Address - Phone:302-731-2888
Mailing Address - Fax:302-731-7049
Practice Address - Street 1:12100 BLACK SWAN DR STE 201
Practice Address - Street 2:
Practice Address - City:LEWES
Practice Address - State:DE
Practice Address - Zip Code:19958-4991
Practice Address - Country:US
Practice Address - Phone:302-644-3311
Practice Address - Fax:302-644-3300
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-23
Last Update Date:2022-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEE10000140213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1000017150Medicaid
DE0001026317Medicaid
1184681488OtherCOMMERCIAL
DE00B502C77Medicare PIN
DE0001026317Medicaid