Healthcare Provider Details

I. General information

NPI: 1548591845
Provider Name (Legal Business Name): MARK NOOTENS, MD, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/26/2010
Last Update Date: 03/16/2021
Certification Date: 03/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

931 FRAN LIN PKWY
MUNSTER IN
46321-3540
US

IV. Provider business mailing address

931 FRAN LIN PKWY
MUNSTER IN
46321-3540
US

V. Phone/Fax

Practice location:
  • Phone: 219-513-0107
  • Fax: 219-513-0108
Mailing address:
  • Phone: 219-513-0107
  • Fax: 219-513-0108

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number01042703
License Number StateIN

VIII. Authorized Official

Name: MRS. NATALIE NOOTENS
Title or Position: OFFICE MANAGER
Credential:
Phone: 219-513-0107