Healthcare Provider Details

I. General information

NPI: 1396827150
Provider Name (Legal Business Name): MARK A WEIGHT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2006
Last Update Date: 06/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2355 CORONADO ST
IDAHO FALLS ID
83404-7407
US

IV. Provider business mailing address

PO BOX 1432
IDAHO FALLS ID
83403-1432
US

V. Phone/Fax

Practice location:
  • Phone: 208-523-0303
  • Fax: 208-523-9815
Mailing address:
  • Phone: 208-552-8770
  • Fax: 208-523-2025

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XX0801X
TaxonomyOrthopaedic Trauma Physician
License NumberM9283
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License NumberM9283
License Number StateID
# 3
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License NumberM9283
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: