Provider Demographics
NPI:1669433462
Name:CASSELLIUS, MARK A (DC)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:A
Last Name:CASSELLIUS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:419 SAND LAKE RD
Mailing Address - Street 2:
Mailing Address - City:ONALASKA
Mailing Address - State:WI
Mailing Address - Zip Code:54650-2706
Mailing Address - Country:US
Mailing Address - Phone:608-783-3307
Mailing Address - Fax:608-779-9728
Practice Address - Street 1:419 SAND LAKE RD
Practice Address - Street 2:
Practice Address - City:ONALASKA
Practice Address - State:WI
Practice Address - Zip Code:54650-2706
Practice Address - Country:US
Practice Address - Phone:608-783-3307
Practice Address - Fax:608-779-9728
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-31
Last Update Date:2011-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2293111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38800700Medicaid
WI350016946OtherRR MEDICARE #
WI350016946OtherRR MEDICARE #