Provider Demographics
NPI:1790993137
Name:FENZL, MARK EDWARD (DO)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:EDWARD
Last Name:FENZL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:216 E LIMA ST
Mailing Address - Street 2:
Mailing Address - City:FOREST
Mailing Address - State:OH
Mailing Address - Zip Code:45843-1118
Mailing Address - Country:US
Mailing Address - Phone:419-273-2553
Mailing Address - Fax:419-273-3337
Practice Address - Street 1:216 E LIMA ST
Practice Address - Street 2:
Practice Address - City:FOREST
Practice Address - State:OH
Practice Address - Zip Code:45843-1118
Practice Address - Country:US
Practice Address - Phone:419-273-2553
Practice Address - Fax:419-273-3337
Is Sole Proprietor?:No
Enumeration Date:2007-05-18
Last Update Date:2009-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.008871208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHP00681969OtherRAILROAD CARE
OH2902854Medicaid
OHP00681969OtherRAILROAD CARE