Healthcare Provider Details

I. General information

NPI: 1811909740
Provider Name (Legal Business Name): MARK C. WYERS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2006
Last Update Date: 05/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 FRANCIS ST SUITE 5B
BOSTON MA
02215-5501
US

IV. Provider business mailing address

110 FRANCIS ST SUITE 5B
BOSTON MA
02215-5501
US

V. Phone/Fax

Practice location:
  • Phone: 617-632-9956
  • Fax:
Mailing address:
  • Phone: 617-632-9956
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number153552
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: