Basic Information
| Provider Information | |||||||||
| NPI: | 1730407321 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WISTHOFF | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | RYAN | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14300 ORCHARD PKWY | ||||||||
| Address2: | PLAZA BUILDING, SUITE 150 CAMPUS BOX 20, | ||||||||
| City: | WESTMINSTER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800239206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034305560 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1201 5TH ST | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802042005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3035562525 | ||||||||
| FaxNumber: | 3035563881 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/06/2010 | ||||||||
| LastUpdateDate: | 02/05/2016 | ||||||||
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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 | 207QS0010X | 50751 | CO | Y | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine |
No ID Information.