Provider Demographics
NPI:1053580696
Name:WILT, MARK T (DPM)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:T
Last Name:WILT
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 365
Mailing Address - Street 2:
Mailing Address - City:PROSPERITY
Mailing Address - State:WV
Mailing Address - Zip Code:25909-0365
Mailing Address - Country:US
Mailing Address - Phone:800-292-3008
Mailing Address - Fax:330-629-9181
Practice Address - Street 1:401 ROGERS ST
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:WV
Practice Address - Zip Code:24740-3636
Practice Address - Country:US
Practice Address - Phone:304-487-9442
Practice Address - Fax:330-629-9181
Is Sole Proprietor?:No
Enumeration Date:2008-02-28
Last Update Date:2009-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV10402213E00000X, 213ES0103X
OH36-003486213E00000X
VA0103301014213ES0103X, 213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00733598OtherRAILROAD MEDICARE
VA1053580696Medicaid
WV3810015482Medicaid
WV3810015482Medicaid
WV4240974Medicare PIN