Provider Demographics
NPI:1730238965
Name:INES, MARK (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:INES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:MARK
Other - Middle Name:
Other - Last Name:SANTA INES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:8106 WHITETAIL DR
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53406-1746
Mailing Address - Country:US
Mailing Address - Phone:262-886-1687
Mailing Address - Fax:
Practice Address - Street 1:8348 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53406-3733
Practice Address - Country:US
Practice Address - Phone:262-884-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI48513207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34807700Medicaid
WI34807700Medicaid