Basic Information
| Provider Information | |||||||||
| NPI: | 1184698482 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROZNIK | ||||||||
| FirstName: | MARK | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | N14W23900 STONE RIDGE DR | ||||||||
| Address2: | PROHEALTH CARE MEDICAL ASSOCIATES INC. | ||||||||
| City: | WAUKESHA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531881135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2625493030 | ||||||||
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| Practice Location | |||||||||
| Address1: | N14W23900 STONE RIDGE DR | ||||||||
| Address2: | PROHEALTH CARE MEDICAL ASSOCIATES INC. | ||||||||
| City: | WAUKESHA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531881135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2625493030 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2006 | ||||||||
| LastUpdateDate: | 11/15/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 29104 | WI | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 31393800 | 05 | WI | MEDICAID |