Provider Demographics
NPI:1760415228
Name:PROMERSBERGER, MARK EDWARD (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:EDWARD
Last Name:PROMERSBERGER
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 1:2002 PROFESSIONAL CT
Mailing Address - Street 2:
Mailing Address - City:MARTINSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:25401-8808
Mailing Address - Country:US
Mailing Address - Phone:304-267-4273
Mailing Address - Fax:304-267-2135
Practice Address - Street 1:2002 PROFESSIONAL CT
Practice Address - Street 2:
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25401-8808
Practice Address - Country:US
Practice Address - Phone:304-267-4273
Practice Address - Fax:304-267-2135
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-08
Last Update Date:2011-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV19369207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0202125000Medicaid
WV0202125000Medicaid
WV9310551Medicare PIN