Healthcare Provider Details

I. General information

NPI: 1033190251
Provider Name (Legal Business Name): DR. MARK STEPHEN BLUE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2005
Last Update Date: 08/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 S. CAMINO DEL RIO B1
DURANGO CO
81303
US

IV. Provider business mailing address

555 S. CAMINO DEL RIO B1
DURANGO CO
81303-4244
US

V. Phone/Fax

Practice location:
  • Phone: 970-385-6800
  • Fax: 970-385-4620
Mailing address:
  • Phone: 970-385-6800
  • Fax: 970-385-4620

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberCO8384
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: