Provider Demographics
NPI:1669534350
Name:THEISS, MARK M (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:M
Last Name:THEISS
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:PO BOX 37174
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21297-3174
Mailing Address - Country:US
Mailing Address - Phone:571-423-5699
Mailing Address - Fax:571-423-5698
Practice Address - Street 1:3300 GALLOWS RD
Practice Address - Street 2:
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22042-3300
Practice Address - Country:US
Practice Address - Phone:703-776-4001
Practice Address - Fax:703-776-7113
Is Sole Proprietor?:No
Enumeration Date:2006-12-16
Last Update Date:2022-01-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0101036798207X00000X, 207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA006499317Medicaid
VA006499317Medicaid
VAB95103Medicare UPIN