Provider Demographics
NPI:1629036116
Name:SNOWISE, MARK (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:SNOWISE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 STOCKBRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:LEE
Mailing Address - State:MA
Mailing Address - Zip Code:01238-9316
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:710 STOCKBRIDGE RD
Practice Address - Street 2:
Practice Address - City:LEE
Practice Address - State:MA
Practice Address - Zip Code:01238-9316
Practice Address - Country:US
Practice Address - Phone:413-243-0122
Practice Address - Fax:413-243-2251
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2019-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA205153207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0103422Medicaid
MA0103422Medicaid
MASNA31371Medicare ID - Type Unspecified