Healthcare Provider Details

I. General information

NPI: 1033196233
Provider Name (Legal Business Name): MARK W MUILENBURG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/28/2005
Last Update Date: 06/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 LINCOLN CIR SE SUITE 100
ORANGE CITY IA
51041-1862
US

IV. Provider business mailing address

1000 LINCOLN CIR SE SUITE 100
ORANGE CITY IA
51041-1862
US

V. Phone/Fax

Practice location:
  • Phone: 712-737-2000
  • Fax: 712-737-2115
Mailing address:
  • Phone: 712-737-2000
  • Fax: 712-737-2115

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number27195
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: