Basic Information
Provider Information | |||||||||
NPI: | 1821096660 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BARNETT | ||||||||
FirstName: | MARK | ||||||||
MiddleName: | GORDON | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 3178 | ||||||||
Address2: |   | ||||||||
City: | CEDAR RAPIDS | ||||||||
State: | IA | ||||||||
PostalCode: | 524063178 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3193981583 | ||||||||
FaxNumber: | 3193992085 | ||||||||
Practice Location | |||||||||
Address1: | 202 10TH STREET SE | ||||||||
Address2: |   | ||||||||
City: | CEDAR RAPIDS | ||||||||
State: | IA | ||||||||
PostalCode: | 524032404 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3193625118 | ||||||||
FaxNumber: | 3193640574 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/13/2005 | ||||||||
LastUpdateDate: | 09/11/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0129X | 29848 | IA | N |   | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery | 208G00000X | 29848 | IA | Y |   | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |   |
ID Information
ID | Type | State | Issuer | Description | 1108258 | 05 | IA |   | MEDICAID | 56501 | 01 | IA | BLUE CROSS/BLUE SHIELD | OTHER |