Basic Information
| Provider Information | |||||||||
| NPI: | 1548334204 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARK | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 201 CEDAR ST SE | ||||||||
| Address2: | STE. 5640 | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871064917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058436168 | ||||||||
| FaxNumber: | 5052479743 | ||||||||
| Practice Location | |||||||||
| Address1: | 201 CEDAR ST SE | ||||||||
| Address2: | STE. 5640 | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871064917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058436168 | ||||||||
| FaxNumber: | 5052479743 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2006 | ||||||||
| LastUpdateDate: | 12/19/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 82-87 | NM | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 33670 | 05 | NM | MEDICAID |