Provider Demographics
NPI:1487615316
Name:CHOUINARD, MARK D (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:D
Last Name:CHOUINARD
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:PO BOX 3755
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68103-0755
Mailing Address - Country:US
Mailing Address - Phone:402-354-2100
Mailing Address - Fax:402-354-6171
Practice Address - Street 1:1120 N 103RD PLZ
Practice Address - Street 2:SUITE 100
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68114-1114
Practice Address - Country:US
Practice Address - Phone:402-391-5055
Practice Address - Fax:402-391-5053
Is Sole Proprietor?:No
Enumeration Date:2006-03-30
Last Update Date:2015-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE18631207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE100264481-00Medicaid
NE100264483-00Medicaid
IA1487615316OtherWELLMARK - RED OAK, IA LOCATION
NE100264489-00Medicaid
IA1487615316Medicaid
IA075120018Medicare PIN
NE100264481-00Medicaid
E20751Medicare UPIN