Healthcare Provider Details

I. General information

NPI: 1821001462
Provider Name (Legal Business Name): MARK EDWARD WEBER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 N 3RD AVE
SANDPOINT ID
83864-1507
US

IV. Provider business mailing address

520 N 3RD AVE
SANDPOINT ID
83864-1507
US

V. Phone/Fax

Practice location:
  • Phone: 208-265-1160
  • Fax: 208-265-1278
Mailing address:
  • Phone: 208-265-1160
  • Fax: 208-265-1278

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberM7384
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: