Provider Demographics
NPI:1093778755
Name:GOETTING, MARK G (MD)
Entity Type:Individual
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First Name:MARK
Middle Name:G
Last Name:GOETTING
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Gender:M
Credentials:MD
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Mailing Address - Street 1:3200 W CENTRE AVE
Mailing Address - Street 2:SUITE 203
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-4889
Mailing Address - Country:US
Mailing Address - Phone:269-324-0799
Mailing Address - Fax:269-324-8013
Practice Address - Street 1:3200 W CENTRE AVE
Practice Address - Street 2:SUITE 203
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-4889
Practice Address - Country:US
Practice Address - Phone:269-324-0799
Practice Address - Fax:269-324-8013
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2023-11-27
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Provider Licenses
StateLicense IDTaxonomies
MI43010449512084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1093778755Medicaid
MI1093778755Medicaid
MI0C97625104Medicare PIN