Provider Demographics
NPI:1982691333
Name:WU, MARK P (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:P
Last Name:WU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2033 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ATHOL
Mailing Address - State:MA
Mailing Address - Zip Code:01331-3535
Mailing Address - Country:US
Mailing Address - Phone:978-249-3511
Mailing Address - Fax:978-249-7666
Practice Address - Street 1:2033 MAIN ST
Practice Address - Street 2:
Practice Address - City:ATHOL
Practice Address - State:MA
Practice Address - Zip Code:01331-3535
Practice Address - Country:US
Practice Address - Phone:978-249-3511
Practice Address - Fax:978-249-7666
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA50555208600000X, 2086S0129X, 208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered208600000XAllopathic & Osteopathic PhysiciansSurgery
Not Answered2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Not Answered208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1392620Medicaid
MA0000038Medicare ID - Type Unspecified
MA1392620Medicaid