Provider Demographics
NPI:1255348900
Name:ROESSLER, MARK LEONARD (DO)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:LEONARD
Last Name:ROESSLER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:55-77 SCHANCK ROAD
Mailing Address - Street 2:SUITE B-9
Mailing Address - City:FREEHOLD
Mailing Address - State:NJ
Mailing Address - Zip Code:07728
Mailing Address - Country:US
Mailing Address - Phone:732-677-3780
Mailing Address - Fax:
Practice Address - Street 1:55-77 SCHANCK ROAD
Practice Address - Street 2:SUITE B-9
Practice Address - City:FREEHOLD
Practice Address - State:NJ
Practice Address - Zip Code:07728
Practice Address - Country:US
Practice Address - Phone:732-677-3780
Practice Address - Fax:732-677-3782
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2011-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB07718700207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
I15728Medicare UPIN
NJ082940BFMMedicare ID - Type Unspecified