Provider Demographics
NPI:1760675193
Name:MARK S WILLNER MD PA
Entity Type:Organization
Organization Name:MARK S WILLNER MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:S
Authorized Official - Last Name:WILLNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:954-851-9690
Mailing Address - Street 1:3820 WINDMILL LAKES RD
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:FL
Mailing Address - Zip Code:33332-2107
Mailing Address - Country:US
Mailing Address - Phone:954-851-9690
Mailing Address - Fax:954-851-9688
Practice Address - Street 1:14201 W SUNRISE BLVD
Practice Address - Street 2:SUITE 208
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33323-3207
Practice Address - Country:US
Practice Address - Phone:954-851-9690
Practice Address - Fax:954-851-9688
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-20
Last Update Date:2010-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL05910Medicare PIN
FLD61310Medicare UPIN