Provider Demographics
NPI:1841322658
Name:CZARNECKI, MARK DENNIS (DO)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:DENNIS
Last Name:CZARNECKI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1580
Mailing Address - Street 2:
Mailing Address - City:THE DALLES
Mailing Address - State:OR
Mailing Address - Zip Code:97058-8004
Mailing Address - Country:US
Mailing Address - Phone:541-296-1919
Mailing Address - Fax:541-296-2253
Practice Address - Street 1:1615 E 12TH ST
Practice Address - Street 2:STE 100
Practice Address - City:THE DALLES
Practice Address - State:OR
Practice Address - Zip Code:97058-8004
Practice Address - Country:US
Practice Address - Phone:541-296-1919
Practice Address - Fax:541-296-2253
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR15400DO207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR152934Medicaid
OR152934Medicaid
OR00WFBSTBMedicare ID - Type Unspecified