Provider Demographics
NPI:1619927985
Name:GEDDEN, MARK S (DO)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:S
Last Name:GEDDEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:507 S MONROE ST
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:WI
Mailing Address - Zip Code:53813-2054
Mailing Address - Country:US
Mailing Address - Phone:608-723-3293
Mailing Address - Fax:608-723-3281
Practice Address - Street 1:507 S MONROE ST
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:WI
Practice Address - Zip Code:53813-2054
Practice Address - Country:US
Practice Address - Phone:608-723-3293
Practice Address - Fax:608-723-3281
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2012-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI36127-021207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30064400Medicaid
WIA82522Medicare UPIN
WI30064400Medicaid