Provider Demographics
NPI:1386766368
Name:HERRING, MARK LEONARD (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:LEONARD
Last Name:HERRING
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 1:1355 JOHNSTON DR
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-2131
Mailing Address - Country:US
Mailing Address - Phone:920-682-2747
Mailing Address - Fax:920-686-1498
Practice Address - Street 1:1355 JOHNSTON DR
Practice Address - Street 2:
Practice Address - City:MANITOWOC
Practice Address - State:WI
Practice Address - Zip Code:54220-2131
Practice Address - Country:US
Practice Address - Phone:920-682-2747
Practice Address - Fax:920-686-1498
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI24825207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIB53578Medicare UPIN