Healthcare Provider Details

I. General information

NPI: 1043208259
Provider Name (Legal Business Name): MARK D GUADAGNOLI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2005
Last Update Date: 12/07/2022
Certification Date: 12/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 ROCKY MOUNTAIN AVE STE 100
LOVELAND CO
80538-9004
US

IV. Provider business mailing address

2500 ROCKY MOUNTAIN AVE SUITE 100
LOVELAND CO
80538-9004
US

V. Phone/Fax

Practice location:
  • Phone: 970-624-1800
  • Fax: 970-624-1891
Mailing address:
  • Phone: 970-624-1800
  • Fax: 970-624-1891

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number29590
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number5495A
License Number StateWY
# 3
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number29590
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: