Provider Demographics
NPI:1508493248
Name:BOISSONNEAULT, MARK ANTHONY (DPM)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:ANTHONY
Last Name:BOISSONNEAULT
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 GLYNDON DR STE 2A
Mailing Address - Street 2:
Mailing Address - City:REISTERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21136-2002
Mailing Address - Country:US
Mailing Address - Phone:410-833-2255
Mailing Address - Fax:
Practice Address - Street 1:4 GLYNDON DR STE 2A
Practice Address - Street 2:
Practice Address - City:REISTERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21136-2002
Practice Address - Country:US
Practice Address - Phone:410-833-2255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-24
Last Update Date:2024-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD01789213E00000X
DEE1-0010279213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE0000827650Medicaid