Provider Demographics
NPI:1134113152
Name:CETTIE, MARK DOUGLAS (DPM)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:DOUGLAS
Last Name:CETTIE
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 S COULTER ST STE P
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79106-1795
Mailing Address - Country:US
Mailing Address - Phone:806-354-8760
Mailing Address - Fax:806-354-8792
Practice Address - Street 1:1900 S COULTER ST STE P
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79106-1795
Practice Address - Country:US
Practice Address - Phone:806-354-8760
Practice Address - Fax:806-354-8792
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-06
Last Update Date:2012-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXTX0974213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0974OtherTX STATE LIC
T12594Medicare UPIN
85441BMedicare ID - Type Unspecified