Provider Demographics
NPI:1073564993
Name:JAMESON, MARK JAMES (MD PHD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:JAMES
Last Name:JAMESON
Suffix:
Gender:M
Credentials:MD PHD
Other - Prefix:
Other - First Name:MARK
Other - Middle Name:JAMES
Other - Last Name:HORNEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1417 S CLIFF AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57105-1062
Mailing Address - Country:US
Mailing Address - Phone:605-504-3000
Mailing Address - Fax:605-504-3001
Practice Address - Street 1:1417 S CLIFF AVE STE 300
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-1062
Practice Address - Country:US
Practice Address - Phone:605-504-3000
Practice Address - Fax:605-504-3001
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2022-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101241309207Y00000X
SD13192207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0487819Medicaid
VA1073564993Medicaid
IAP00347197OtherMEDICARE RAILROAD
IA20003OtherWELLMARK BCBS
I51695Medicare UPIN
VA014245U92Medicare PIN
VA1073564993Medicaid