Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 213E00000X | Podiatrist | 0103301014 | VA |
N | 222Z00000X | Podiatrist | 0103301014 | VA |
N | 213E00000X | Podiatrist | 10402 | WV |
N | 222Z00000X | Podiatrist | 10402 | WV |
N | 213E00000X | Podiatrist | 36-003486 | OH |
N | 222Z00000X | Podiatrist | 36-003486 | OH |
Y | 213ES0103X | Foot & Ankle Surgery | 0103301014 | VA |
N | 213ES0103X | Foot & Ankle Surgery | 10402 | WV |
NPI | 1053580696 |
---|---|
Provider Name | Dr. Mark T Wilt |
First Address | Prosperity, WV 25909-0365 |
Second Address | Princeton, WV 24740-3636 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 28/02/2008 |
Last Update Date | 01/10/2009 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1053580696 | (05) | VA |
3810015482 | (05) | WV |
P00733598 | RAILROAD MEDICARE (01) |