Provider Demographics
NPI:1871653691
Name:WIPFLER, MARK GUSTAV (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:GUSTAV
Last Name:WIPFLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:43 HINMAN LN W
Mailing Address - Street 2:
Mailing Address - City:SOUTHBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06488-3828
Mailing Address - Country:US
Mailing Address - Phone:203-262-4443
Mailing Address - Fax:203-262-4423
Practice Address - Street 1:43 HINMAN LN W
Practice Address - Street 2:
Practice Address - City:SOUTHBURY
Practice Address - State:CT
Practice Address - Zip Code:06488-3828
Practice Address - Country:US
Practice Address - Phone:203-262-4443
Practice Address - Fax:203-262-4423
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2014-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT031943207PE0004X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
930032965OtherRAILROAD MEDICARE
930000321Medicare PIN
CTE17668Medicare UPIN