Provider Demographics
NPI:1750325155
Name:BOETTCHER, MARK C (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:C
Last Name:BOETTCHER
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 1:3200 E RACINE ST
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53546-2343
Mailing Address - Country:US
Mailing Address - Phone:608-371-8000
Mailing Address - Fax:608-371-8919
Practice Address - Street 1:3200 E RACINE ST
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53546-2343
Practice Address - Country:US
Practice Address - Phone:608-371-8000
Practice Address - Fax:608-371-8008
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI33859-020208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1750325155Medicaid
WI32076500Medicaid
WIK400110896Medicare PIN
WI543400512Medicare PIN
WI32076500Medicaid