Provider Demographics
NPI:1982693727
Name:BOHL, MARK ROBERT (DC)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:ROBERT
Last Name:BOHL
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT HOREB
Mailing Address - State:WI
Mailing Address - Zip Code:53572-2082
Mailing Address - Country:US
Mailing Address - Phone:608-437-5000
Mailing Address - Fax:608-437-5019
Practice Address - Street 1:310 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MOUNT HOREB
Practice Address - State:WI
Practice Address - Zip Code:53572-2082
Practice Address - Country:US
Practice Address - Phone:608-437-5000
Practice Address - Fax:608-437-5019
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-14
Last Update Date:2012-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1561012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38907800Medicaid
WI38907800Medicaid
75127Medicare ID - Type Unspecified