Healthcare Provider Details

I. General information

NPI: 1568491975
Provider Name (Legal Business Name): MARK THOMAS NOOTENS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2006
Last Update Date: 09/08/2022
Certification Date: 09/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

931 FRAN LIN PKWY
MUNSTER IN
46321-3540
US

IV. Provider business mailing address

14125 HUSEMAN ST
CEDAR LAKE IN
46303-9316
US

V. Phone/Fax

Practice location:
  • Phone: 219-513-0107
  • Fax: 219-513-0108
Mailing address:
  • Phone: 219-781-3191
  • Fax:

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:
Title or Position:
Credential:
Phone: