Healthcare Provider Details

I. General information

NPI: 1811257231
Provider Name (Legal Business Name): MARK ANTHONY WEITZEL D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2012
Last Update Date: 09/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

122 12TH ST STE A
PRINCETON WV
24740-2312
US

IV. Provider business mailing address

PO BOX 1369
PRINCETON WV
24740-1369
US

V. Phone/Fax

Practice location:
  • Phone: 304-487-3407
  • Fax: 304-487-1052
Mailing address:
  • Phone: 304-431-5168
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License Number3125
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: