Healthcare Provider Details

I. General information

NPI: 1174764906
Provider Name (Legal Business Name): MARK W NIEDFELDT, MD, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2009
Last Update Date: 03/06/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10556 N PORT WASHINGTON RD STE 101
MEQUON WI
53092-5586
US

IV. Provider business mailing address

10556 N PORT WASHINGTON RD SUITE 101
MEQUON WI
53092-5586
US

V. Phone/Fax

Practice location:
  • Phone: 262-643-4720
  • Fax: 262-643-4721
Mailing address:
  • Phone: 262-643-4720
  • Fax: 262-643-4721

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35201
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number35201
License Number StateWI

VIII. Authorized Official

Name: DR. MARK W NIEDFELDT
Title or Position: OWNER
Credential: M.D.
Phone: 262-643-4720