Provider Demographics
NPI:1891791067
Name:HEBERLEIN, MARK S (DO)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:S
Last Name:HEBERLEIN
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:PO BOX 39
Mailing Address - Street 2:
Mailing Address - City:CASHTON
Mailing Address - State:WI
Mailing Address - Zip Code:54619-0039
Mailing Address - Country:US
Mailing Address - Phone:608-654-5100
Mailing Address - Fax:608-654-5120
Practice Address - Street 1:238 FRONT ST
Practice Address - Street 2:
Practice Address - City:CASHTON
Practice Address - State:WI
Practice Address - Zip Code:54619-2002
Practice Address - Country:US
Practice Address - Phone:608-654-5100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI36061204D00000X, 207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30064000Medicaid
WI0398Medicare PIN
WI30064000Medicaid