Provider Demographics
NPI:1205063211
Name:MIEDEMA, MARK L (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:L
Last Name:MIEDEMA
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:3317 N WIMBERLY DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-4056
Mailing Address - Country:US
Mailing Address - Phone:479-521-2752
Mailing Address - Fax:479-521-4603
Practice Address - Street 1:3317 N WIMBERLY DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-4056
Practice Address - Country:US
Practice Address - Phone:479-521-2752
Practice Address - Fax:479-443-7862
Is Sole Proprietor?:No
Enumeration Date:2009-06-17
Last Update Date:2025-03-19
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
ARE-9691208100000X, 2081P2900X
FL13487207Q00000X
CO494372081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO357181YPYZMedicare PIN