Basic Information
| Provider Information | |||||||||
| NPI: | 1982662102 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DONALDSON | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1055 N 500 W | ||||||||
| Address2: | CREDENTIALING DEPARTMENT | ||||||||
| City: | PROVO | ||||||||
| State: | UT | ||||||||
| PostalCode: | 846043305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013548225 | ||||||||
| FaxNumber: | 8014180941 | ||||||||
| Practice Location | |||||||||
| Address1: | 1055 N 500 W | ||||||||
| Address2: | SUITE 111 | ||||||||
| City: | PROVO | ||||||||
| State: | UT | ||||||||
| PostalCode: | 846043305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013748999 | ||||||||
| FaxNumber: | 8014298063 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2006 | ||||||||
| LastUpdateDate: | 08/28/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | 1678601205 | UT | Y | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | 03-00069 | 01 | UT | UNITED HEALTHCARE | OTHER | 070003257 | 01 | UT | PALMETTO GBA | OTHER | 870281028DO1 | 01 | UT | EMIA | OTHER | 107006212101 | 01 | UT | IHC HEALTHPLANS | OTHER | 4081 | 01 | UT | DMBA | OTHER | 6603 | 01 | UT | PEHP | OTHER | QM0000037164 | 01 | UT | ALTIUS | OTHER |