Basic Information
| Provider Information | |||||||||
| NPI: | 1881622629 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SCHWARTZ | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 110 E ROUTT AVE | ||||||||
| Address2: | |||||||||
| City: | PUEBLO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810042117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195438711 | ||||||||
| FaxNumber: | 7195435340 | ||||||||
| Practice Location | |||||||||
| Address1: | 1302 E 5TH ST | ||||||||
| Address2: | |||||||||
| City: | PUEBLO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810013754 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195438711 | ||||||||
| FaxNumber: | 7195435340 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2006 | ||||||||
| LastUpdateDate: | 02/05/2014 | ||||||||
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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 | 207R00000X | 37095 | CO | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 208000000X | 37095 | CO | N | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 02156202 | 05 | CO | MEDICAID |