Provider Demographics
NPI:1649224809
Name:EBERTZ, JOSEPH MARK (MD)
Entity type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:MARK
Last Name:EBERTZ
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 1:401 N 9TH ST
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501-4507
Mailing Address - Country:US
Mailing Address - Phone:701-712-4500
Mailing Address - Fax:701-712-4098
Practice Address - Street 1:2700 STATE ST
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58503-0669
Practice Address - Country:US
Practice Address - Phone:701-712-4500
Practice Address - Fax:701-712-4011
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND5421207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND070015671OtherMEDICARE RAILROAD
ND11591Medicaid
ND20636Medicare ID - Type Unspecified
NDD25847Medicare UPIN