Provider Demographics
NPI:1063414613
Name:WEISENFLUH, MARK GERARD (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:GERARD
Last Name:WEISENFLUH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 STATE ST
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16550-0002
Mailing Address - Country:US
Mailing Address - Phone:814-877-4922
Mailing Address - Fax:814-877-3622
Practice Address - Street 1:201 STATE ST
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16550-0002
Practice Address - Country:US
Practice Address - Phone:814-877-4922
Practice Address - Fax:814-877-3622
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2020-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD041983L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1038289OtherGATEWAY
PA185778OtherUNISON
PA845062OtherAETNA
PAP00170314OtherRR MEDICARE
NY01862160OtherNY MEDICAID
PA0012697800001Medicaid
OH0934850OtherOH MEDICAID
WV1069022OtherWEST VIRGINIA WORK COMP
NY00025797101OtherUNIVERA
PA212698OtherUPMC
PA657705OtherBLUE SHIELD
NY01862160OtherNY MEDICAID
PA657705OtherBLUE SHIELD