Provider Demographics
NPI:1902869399
Name:WINOGRAD, MARK (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:WINOGRAD
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 1:5757 W THUNDERBIRD RD
Mailing Address - Street 2:STE E151
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85306
Mailing Address - Country:US
Mailing Address - Phone:602-843-3811
Mailing Address - Fax:602-843-0044
Practice Address - Street 1:5757 W THUNDERBIRD RD
Practice Address - Street 2:STE E151
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85306
Practice Address - Country:US
Practice Address - Phone:602-843-3811
Practice Address - Fax:602-843-0044
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ139922084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ20640001Medicaid
E46553Medicare UPIN
AZZMD13992Medicare ID - Type Unspecified