Provider Demographics
NPI:1003889262
Name:OTT, MARK JOHN (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:JOHN
Last Name:OTT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5169 S COTTONWOOD ST
Mailing Address - Street 2:SUITE 400
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-6767
Mailing Address - Country:US
Mailing Address - Phone:801-507-3462
Mailing Address - Fax:801-507-3061
Practice Address - Street 1:5169 S COTTONWOOD ST
Practice Address - Street 2:SUITE 400
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-6767
Practice Address - Country:US
Practice Address - Phone:801-507-3462
Practice Address - Fax:801-507-3061
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1538992086X0206X
UT5135057-12052086X0206X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
E96317Medicare UPIN