Healthcare Provider Details

I. General information

NPI: 1417303405
Provider Name (Legal Business Name): MARK WINTER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2016
Last Update Date: 01/15/2025
Certification Date: 01/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2330 UTAH AVE STE 200
EL SEGUNDO CA
90245-4817
US

IV. Provider business mailing address

3612 GRANT CT
FLOWER MOUND TX
75022-5117
US

V. Phone/Fax

Practice location:
  • Phone: 281-766-0959
  • Fax:
Mailing address:
  • Phone: 920-574-0143
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number12215487-1205
License Number StateUT
# 3
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberME165038
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: