Provider Demographics
NPI:1700896487
Name:WEIGLE, MARK R (MD)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:R
Last Name:WEIGLE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:140 LOCKWOOD AVE # A
Mailing Address - Street 2:SUITE #2
Mailing Address - City:NEW ROCHELLE
Mailing Address - State:NY
Mailing Address - Zip Code:10801-4915
Mailing Address - Country:US
Mailing Address - Phone:914-636-4466
Mailing Address - Fax:914-636-0611
Practice Address - Street 1:140 LOCKWOOD AVE # A
Practice Address - Street 2:SUITE #2
Practice Address - City:NEW ROCHELLE
Practice Address - State:NY
Practice Address - Zip Code:10801-4915
Practice Address - Country:US
Practice Address - Phone:914-636-4466
Practice Address - Fax:914-636-0611
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2008-03-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY2110991208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02068720Medicaid
24Z281Medicare ID - Type Unspecified
G75506Medicare UPIN