Basic Information
| Provider Information | |||||||||
| NPI: | 1326038555 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DOUTHIT | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | B | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2500 ROCKY MOUNTAIN AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | LOVELAND | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805389004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9706241800 | ||||||||
| FaxNumber: | 9706241891 | ||||||||
| Practice Location | |||||||||
| Address1: | 2301 HOUSE AVE STE 301B | ||||||||
| Address2: | |||||||||
| City: | CHEYENNE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 820013176 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3077781849 | ||||||||
| FaxNumber: | 3077784995 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2005 | ||||||||
| LastUpdateDate: | 04/05/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 29696 | CO | N | Allopathic & Osteopathic Physicians | Surgery | 208G00000X | 29696 | CO | N | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) | 208G00000X | 11195A | WY | Y | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
ID Information
| ID | Type | State | Issuer | Description | 01296961 | 05 | CO | MEDICAID | 1326038555 | 05 | NE | MEDICAID | 133577400 | 05 | WY | MEDICAID | P00970361 | 01 | CO | RAILROAD MEDICARE PTAN | OTHER |