Provider Demographics
NPI:1700040565
Name:ROSENGREN, MARK JEREMY (DO)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:JEREMY
Last Name:ROSENGREN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 MCDOUGAL DR
Mailing Address - Street 2:
Mailing Address - City:HOLDENVILLE
Mailing Address - State:OK
Mailing Address - Zip Code:74848-2822
Mailing Address - Country:US
Mailing Address - Phone:405-379-4259
Mailing Address - Fax:405-379-4252
Practice Address - Street 1:100 MCDOUGAL DR
Practice Address - Street 2:
Practice Address - City:HOLDENVILLE
Practice Address - State:OK
Practice Address - Zip Code:74848-2822
Practice Address - Country:US
Practice Address - Phone:405-379-4201
Practice Address - Fax:405-379-4264
Is Sole Proprietor?:No
Enumeration Date:2008-07-10
Last Update Date:2023-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK8261207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD000Medicare UPIN