Provider Demographics
NPI:1891878716
Name:BREKKE, MARK KEVIN (DPM, FACFAS)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:KEVIN
Last Name:BREKKE
Suffix:
Gender:M
Credentials:DPM, FACFAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2155 W HIGHWAY 89A STE 116
Mailing Address - Street 2:
Mailing Address - City:SEDONA
Mailing Address - State:AZ
Mailing Address - Zip Code:86336-5415
Mailing Address - Country:US
Mailing Address - Phone:928-282-3138
Mailing Address - Fax:928-282-3187
Practice Address - Street 1:2155 W HIGHWAY 89A STE 116
Practice Address - Street 2:
Practice Address - City:SEDONA
Practice Address - State:AZ
Practice Address - Zip Code:86336-5415
Practice Address - Country:US
Practice Address - Phone:928-282-3138
Practice Address - Fax:928-282-3187
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2007-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0475213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ423179Medicaid
AZ1243350001Medicare NSC
AZ423179Medicaid
AZZ20255Medicare ID - Type UnspecifiedMEDICARE NUMBER