Provider Demographics
NPI:1932107521
Name:WILES, MARK A (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:WILES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9001 STATE LINE RD # 300
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64114-3232
Mailing Address - Country:US
Mailing Address - Phone:816-363-2600
Mailing Address - Fax:816-523-0068
Practice Address - Street 1:9001 STATE LINE RD # 300
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64114-3232
Practice Address - Country:US
Practice Address - Phone:816-363-2600
Practice Address - Fax:816-523-0068
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018030469207QH0002X
NE27317207Q00000X
IA40843207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Yes207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200259500BMedicaid
KS200259500BMedicaid
KS104584Medicare ID - Type Unspecified