Healthcare Provider Details

I. General information

NPI: 1730407321
Provider Name (Legal Business Name): MARK RYAN WISTHOFF D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2010
Last Update Date: 05/30/2023
Certification Date: 05/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4660 YOSEMITE ST STE 100
DENVER CO
80238-4481
US

IV. Provider business mailing address

2695 ROCKY MOUNTAIN AVE STE 150
LOVELAND CO
80538-9071
US

V. Phone/Fax

Practice location:
  • Phone: 720-516-8902
  • Fax: 720-516-8903
Mailing address:
  • Phone: 970-624-4451
  • Fax: 970-490-4199

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number50751
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberDR.0050751
License Number StateCO
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDR.0050751
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: