Healthcare Provider Details

I. General information

NPI: 1326038555
Provider Name (Legal Business Name): MARK B DOUTHIT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2005
Last Update Date: 04/05/2021
Certification Date: 04/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 HOUSE AVE STE 301B
CHEYENNE WY
82001-3176
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 307-778-1849
  • Fax: 307-778-4995
Mailing address:
  • Phone: 970-624-1800
  • Fax: 970-624-1891

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number29696
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number29696
License Number StateCO
# 3
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number11195A
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: