Provider Demographics
NPI:1316141914
Name:WEISBROD, MARK ANDREW (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:ANDREW
Last Name:WEISBROD
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 1:2920 N CASCADE AVE
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80907-6262
Mailing Address - Country:US
Mailing Address - Phone:719-636-3937
Mailing Address - Fax:
Practice Address - Street 1:2920 N CASCADE AVE
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80907-6262
Practice Address - Country:US
Practice Address - Phone:719-636-3937
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-14
Last Update Date:2008-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP1-0018217207W00000X
FLME99294207W00000X
CO46910207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
947425800OtherMYUTMB 947425800-COMMERCIAL NUMBER