Basic Information
| Provider Information | |||||||||
| NPI: | 1912006016 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STEFFENSEN | ||||||||
| FirstName: | MARK | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2975 EXECUTIVE PKWY | ||||||||
| Address2: | 200 | ||||||||
| City: | LEHI | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840439642 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8019901911 | ||||||||
| FaxNumber: | 8019901912 | ||||||||
| Practice Location | |||||||||
| Address1: | 1034 N 500 W | ||||||||
| Address2: | |||||||||
| City: | PROVO | ||||||||
| State: | UT | ||||||||
| PostalCode: | 846043380 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8019939582 | ||||||||
| FaxNumber: | 8017335618 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2006 | ||||||||
| LastUpdateDate: | 07/17/2009 | ||||||||
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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 | 207L00000X | 87-177636-1205 | UT | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 37822 | 01 | UT | PEHP | OTHER | 825169 | 05 | AZ | MEDICAID | 804273100 | 05 | ID | MEDICAID | 09071 | 05 | UT | MEDICAID | 0020878700 | 05 | NV | MEDICAID | 107006556101 | 01 | UT | IHC | OTHER | 119682100 | 05 | WY | MEDICAID | 2090168 20-00312 | 01 | UT | UHC | OTHER | 870545614 84121 A029 | 01 | UT | TRICARE | OTHER | 870545614ST2 | 01 | UT | EDUCATORS MUTUAL | OTHER | PRA01907 | 01 | UT | MOLINA | OTHER | 18414 | 01 | UT | DMBA | OTHER |