Provider Demographics
NPI:1710958780
Name:FENZL, MARK (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:FENZL
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 1314
Mailing Address - Street 2:
Mailing Address - City:ORCHARD PARK
Mailing Address - State:NY
Mailing Address - Zip Code:14127-8314
Mailing Address - Country:US
Mailing Address - Phone:716-535-0741
Mailing Address - Fax:716-650-5745
Practice Address - Street 1:224 E MAIN ST
Practice Address - Street 2:
Practice Address - City:SPRINGVILLE
Practice Address - State:NY
Practice Address - Zip Code:14141-1443
Practice Address - Country:US
Practice Address - Phone:716-592-2871
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2020-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1794832085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01560085Medicaid
NY1609207OtherINDEPENDENT HEALTH
NY00026347207OtherUNIVERA
NY0156885OtherGHI
NY01560085Medicaid
NY000524745011OtherBCBS WESTERN NY
NYRB4208Medicare PIN
NYF73791Medicare UPIN