Healthcare Provider Details

I. General information

NPI: 1902903198
Provider Name (Legal Business Name): MARK C DUSTER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 09/05/2018
Certification Date:
Deactivation Date: 05/15/2017
Reactivation Date: 09/05/2018

III. Provider practice location address

1400 E BOULDER ST MEMORIAL CHILDRENS HOSPITAL
COLORADO SPRINGS CO
80909-5533
US

IV. Provider business mailing address

1400 E BOULDER ST MEMORIAL CHILDRENS HOSPITAL
COLORADO SPRINGS CO
80909-5533
US

V. Phone/Fax

Practice location:
  • Phone: 719-365-9543
  • Fax: 719-365-5530
Mailing address:
  • Phone: 719-365-9543
  • Fax: 719-365-5530

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number21521
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: