Provider Demographics
NPI:1316930092
Name:KONWISER, MARK (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:KONWISER
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 1:900 PINE ST
Mailing Address - Street 2:BLDG 1 STE 122/123
Mailing Address - City:ENGLEWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:34223-4418
Mailing Address - Country:US
Mailing Address - Phone:941-474-8811
Mailing Address - Fax:941-473-0058
Practice Address - Street 1:900 PINE ST
Practice Address - Street 2:BLDG 1 STE 122/123
Practice Address - City:ENGLEWOOD
Practice Address - State:FL
Practice Address - Zip Code:34223-4418
Practice Address - Country:US
Practice Address - Phone:941-474-8811
Practice Address - Fax:941-473-0058
Is Sole Proprietor?:No
Enumeration Date:2005-08-26
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME00050766174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL22-0003555OtherRAIL ROAD MEDICARE
FL85944OtherOCCUPATIONAL LICENSE
FL65-0596347OtherFEDERAL TAX #
FL10D0295356OtherCLIA #
FLME00050766OtherFL LIC NUMBER
FLME00050766OtherFL LIC NUMBER
FLB82910Medicare UPIN
FL03734Medicare ID - Type Unspecified