Healthcare Provider Details

I. General information

NPI: 1386766368
Provider Name (Legal Business Name): MARK LEONARD HERRING M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1355 JOHNSTON DR
MANITOWOC WI
54220-2131
US

IV. Provider business mailing address

1355 JOHNSTON DR
MANITOWOC WI
54220-2131
US

V. Phone/Fax

Practice location:
  • Phone: 920-682-2747
  • Fax: 920-686-1498
Mailing address:
  • Phone: 920-682-2747
  • Fax: 920-686-1498

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number24825
License Number StateWI

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: