Provider Demographics
NPI:1750497350
Name:MARK KONWISER MD PA
Entity Type:Organization
Organization Name:MARK KONWISER MD PA
Other - Org Name:MARK KONWISER MD PA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:KONWISER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:941-474-8811
Mailing Address - Street 1:900 PINE ST
Mailing Address - Street 2:BLDG 1 STE 122
Mailing Address - City:ENGLEWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:34223-4418
Mailing Address - Country:US
Mailing Address - Phone:941-474-8811
Mailing Address - Fax:941-473-0058
Practice Address - Street 1:900 PINE ST
Practice Address - Street 2:BLDG 1 STE 122
Practice Address - City:ENGLEWOOD
Practice Address - State:FL
Practice Address - Zip Code:34223-4418
Practice Address - Country:US
Practice Address - Phone:941-474-8811
Practice Address - Fax:941-473-0058
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-23
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME00050766207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL85944OtherOCCUPATIONAL LICENSE
FLME00050766OtherLIC NUMBER FLORIDA
FL22-0003555OtherRAIL ROAD MEDICARE #
FL10D0295356OtherCLIA #
FL=========OtherFEDERAL TAX ID#
FLB82910Medicare UPIN