Healthcare Provider Details

I. General information

NPI: 1134147861
Provider Name (Legal Business Name): MARK E COLLITON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 01/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1233 34TH ST NW
BEMIDJI MN
56601-5112
US

IV. Provider business mailing address

1233 34TH ST NW
BEMIDJI MN
56601-5112
US

V. Phone/Fax

Practice location:
  • Phone: 218-333-5289
  • Fax: 218-759-5021
Mailing address:
  • Phone: 218-333-5289
  • Fax: 218-759-5021

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number36877
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: