Healthcare Provider Details

I. General information

NPI: 1437159944
Provider Name (Legal Business Name): MARK C DEIBERT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2005
Last Update Date: 10/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

536 COTTONWOOD RD SUITE 100
BOZEMAN MT
59718
US

IV. Provider business mailing address

536 COTTONWOOD RD SUITE 100
BOZEMAN MT
59718
US

V. Phone/Fax

Practice location:
  • Phone: 406-586-8029
  • Fax: 406-586-8009
Mailing address:
  • Phone: 406-586-8029
  • Fax: 406-586-8009

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number8221
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: