Provider Demographics
NPI:1457379240
Name:WINKLE, MARK ROBERT (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ROBERT
Last Name:WINKLE
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 1:655 KENMOOR AVE SE
Mailing Address - Street 2:SUITE A
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-8622
Mailing Address - Country:US
Mailing Address - Phone:616-575-1212
Mailing Address - Fax:616-575-1219
Practice Address - Street 1:655 KENMOOR AVE SE
Practice Address - Street 2:SUITE A
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-8622
Practice Address - Country:US
Practice Address - Phone:616-575-1212
Practice Address - Fax:616-575-1219
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2008-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIMW075576207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4212922Medicaid
MI0D11035OtherBLUE CROSS BLUE SHIELD
MI40015120OtherRAILROAD MEDICARE
MIP58750002Medicare PIN
MIH14640Medicare UPIN
MION10350Medicare ID - Type Unspecified