Provider Demographics
NPI:1063419844
Name:NIEDEREE, MARK J (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:J
Last Name:NIEDEREE
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:551 N HILLSIDE ST STE 201
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67214-4923
Mailing Address - Country:US
Mailing Address - Phone:316-263-0296
Mailing Address - Fax:316-263-9523
Practice Address - Street 1:1515 S CLIFTON AVE STE 250
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67218-2952
Practice Address - Country:US
Practice Address - Phone:316-686-1991
Practice Address - Fax:316-686-2309
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2021-08-02
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Provider Licenses
StateLicense IDTaxonomies
KS0427729208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100455310AMedicaid
KS100455310AMedicaid
KS102878Medicare ID - Type Unspecified