Provider Demographics
NPI:1205887775
Name:NIEDFELDT, MARK W (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:W
Last Name:NIEDFELDT
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:10556 NORTH PORT WASHINGTON ROAD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-5586
Mailing Address - Country:US
Mailing Address - Phone:262-643-4720
Mailing Address - Fax:262-643-4721
Practice Address - Street 1:10325 N PORT WASHINGTON RD STE 150
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-5768
Practice Address - Country:US
Practice Address - Phone:262-643-4720
Practice Address - Fax:262-643-4721
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2024-09-24
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Provider Licenses
StateLicense IDTaxonomies
WI35201207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32113600Medicaid
002000187COtherHUMANA
G02954Medicare UPIN
WI32113600Medicaid