Basic Information
| Provider Information | |||||||||
| NPI: | 1437125697 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DEPPER | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | HOWARD | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8020 CONSTITUTION PLACE NE | ||||||||
| Address2: | #202 | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 87110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059983096 | ||||||||
| FaxNumber: | 5059983100 | ||||||||
| Practice Location | |||||||||
| Address1: | 8020 CONSTITUTION PL NE | ||||||||
| Address2: | #101 | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871107607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059981317 | ||||||||
| FaxNumber: | 5059981308 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2006 | ||||||||
| LastUpdateDate: | 06/25/2008 | ||||||||
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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 | 2085R0202X | 94231 | NM | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 18183 | 05 | NM | MEDICAID | 197956 | 05 | AZ | MEDICAID |