Individual
MARK KONWISER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
900 PINE ST, BLDG 1 STE 122/123, ENGLEWOOD, FL 34223-4418
(941) 474-8811
(941) 473-0058
Mailing address
900 PINE ST, BLDG 1 STE 122/123, ENGLEWOOD, FL 34223-4418
(941) 474-8811
(941) 473-0058
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
ME00050766
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
10D0295356
CLIA #
FL
01
—
22-0003555
RAIL ROAD MEDICARE
FL
01
—
65-0596347
FEDERAL TAX #
FL
01
—
85944
OCCUPATIONAL LICENSE
FL
01
—
ME00050766
FL LIC NUMBER
FL
Enumeration date
08/26/2005
Last updated
03/07/2023
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