Provider Demographics
NPI:1639149545
Name:FESEN, MARK (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:FESEN
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:PO BOX 256
Mailing Address - Street 2:2337 E CRAWFORD ST
Mailing Address - City:SALINA
Mailing Address - State:KS
Mailing Address - Zip Code:67401
Mailing Address - Country:US
Mailing Address - Phone:785-823-0633
Mailing Address - Fax:785-823-0658
Practice Address - Street 1:204 CLEVELAND ST
Practice Address - Street 2:
Practice Address - City:GREAT BEND
Practice Address - State:KS
Practice Address - Zip Code:67530-3563
Practice Address - Country:US
Practice Address - Phone:620-792-5511
Practice Address - Fax:620-792-5977
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-24425207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200484450AMedicaid
KS016701006OtherMEDICARE PTAN
KS100143470NMedicaid
KS100143470EMedicaid
OK200484450AMedicaid
KSKA3434007Medicare PIN
KS016701006OtherMEDICARE PTAN