Provider Demographics
NPI:1962438341
Name:WIENPAHL, MARK (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:WIENPAHL
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 1:319 N MILPAS ST
Mailing Address - Street 2:
Mailing Address - City:SANTA BARBARA
Mailing Address - State:CA
Mailing Address - Zip Code:93103-3262
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:271 N FAIRVIEW AVE STE 101
Practice Address - Street 2:
Practice Address - City:GOLETA
Practice Address - State:CA
Practice Address - Zip Code:93117-6284
Practice Address - Country:US
Practice Address - Phone:805-898-0355
Practice Address - Fax:805-682-6933
Is Sole Proprietor?:No
Enumeration Date:2006-06-25
Last Update Date:2022-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO23375207Q00000X
CAG88817207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
6003610001OtherPALMETTO DME
NMNM009J54OtherBCBS
COWIW34932OtherBCBS
CO01233758Medicaid
NMNM009J54OtherBCBS
COD84565Medicare UPIN