Provider Demographics
NPI:1124055314
Name:PUFFENBERGER, MARK W (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:W
Last Name:PUFFENBERGER
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 1:17978 SR 55
Mailing Address - Street 2:
Mailing Address - City:BAKER
Mailing Address - State:WV
Mailing Address - Zip Code:26801-0097
Mailing Address - Country:US
Mailing Address - Phone:304-897-5915
Mailing Address - Fax:
Practice Address - Street 1:111 S GROVE ST STE 1
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:WV
Practice Address - Zip Code:26847-1805
Practice Address - Country:US
Practice Address - Phone:304-257-2451
Practice Address - Fax:304-257-1263
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD040604E207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001162845Medicaid
512783Medicare ID - Type Unspecified
PA001162845Medicaid