MEDICARE: DR. MARK W LODES MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	40194	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	006006261M	OTHER	HUMANA
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1265483739
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK W LODES MD

Provider Business Mailing Address
First Line	:	1155 N MAYFAIR RD
Second Line	:	PLANK ROAD CLINIC
City	:	MILWAUKEE
State	:	WI
Zip	:	53226-3421
Country	:	US
Telephone Number	:	414-955-5990
Fax Number	:	414-955-6282

Provider Business Practice Location Address
First Line	:	1155 N MAYFAIR RD
Second Line	:	PLANK ROAD CLINIC
City	:	MILWAUKEE
State	:	WI
Zip	:	53226-3421
Country	:	US
Telephone Number	:	414-955-5990
Fax Number	:	414-955-6282

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/12/2006
Last Update Date	:	11/08/2012

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Directions to “ DR. MARK W LODES MD” Practice Location

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