Provider Demographics
NPI:1043571458
Name:HIMES, MARK (DO)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:HIMES
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:622 W MAPLE ST
Mailing Address - Street 2:STE B
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-6589
Mailing Address - Country:US
Mailing Address - Phone:505-327-4867
Mailing Address - Fax:
Practice Address - Street 1:622 W MAPLE ST
Practice Address - Street 2:STE B
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-6590
Practice Address - Country:US
Practice Address - Phone:505-327-4867
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-01
Last Update Date:2017-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMA-1969-16207QS0010X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program