Provider Demographics
NPI:1093876138
Name:STOVER, MARK CONRAD (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:CONRAD
Last Name:STOVER
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 1:705 N SAN FRANCISCO ST
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-3232
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:436 5TH AVE
Practice Address - Street 2:
Practice Address - City:KOTZEBUE
Practice Address - State:AK
Practice Address - Zip Code:99752
Practice Address - Country:US
Practice Address - Phone:907-442-7148
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2016-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-34374207P00000X
CAC55475207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine