Provider Demographics
NPI:1396278891
Name:AHLENIUS, MARK (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:AHLENIUS
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 1:3551 ROGER BROOKE DR
Mailing Address - Street 2:SAN ANTONIO MILITARY MEDICAL CENTER, PEDIATRIC RESIDENC
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78234-4504
Mailing Address - Country:US
Mailing Address - Phone:210-916-3160
Mailing Address - Fax:
Practice Address - Street 1:9040 A JACKSON AVE MADIGAN ARMY MEDICAL CENTER
Practice Address - Street 2:
Practice Address - City:JOINT BASE LEWIS MCCHORD
Practice Address - State:WA
Practice Address - Zip Code:98431-4504
Practice Address - Country:US
Practice Address - Phone:253-968-1110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-11
Last Update Date:2024-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101266050208000000X, 208D00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program