Basic Information
| Provider Information | |||||||||
| NPI: | 1841350659 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WEHRY | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | A. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2699 | ||||||||
| Address2: | |||||||||
| City: | PENSACOLA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325132699 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8504754686 | ||||||||
| FaxNumber: | 8504754619 | ||||||||
| Practice Location | |||||||||
| Address1: | 23 MACK BAYOU LOOP STE 100 | ||||||||
| Address2: | |||||||||
| City: | SANTA ROSA BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 324592606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8504161575 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/11/2006 | ||||||||
| LastUpdateDate: | 04/09/2018 | ||||||||
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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 | 2088P0231X | ME73290 | FL | Y | Allopathic & Osteopathic Physicians | Urology | Pediatric Urology | 208800000X | ME73290 | FL | N | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 009940512 | 05 | AL | MEDICAID | 252898300 | 05 | FL | MEDICAID |