Provider Demographics
NPI:1912936527
Name:ENSBERG, MARK DOUGLAS (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:DOUGLAS
Last Name:ENSBERG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:804 SERVICE RD STE A109B
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48824-7015
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5091 WILLOUGHBY RD
Practice Address - Street 2:
Practice Address - City:HOLT
Practice Address - State:MI
Practice Address - Zip Code:48842-1054
Practice Address - Country:US
Practice Address - Phone:517-694-2144
Practice Address - Fax:517-694-6570
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2019-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301048610207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2655771Medicaid
MI2655771Medicaid
MI0C36082090Medicare PIN