Provider Demographics
NPI:1184681082
Name:MUETTERTIES, MARK CONRAD (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:CONRAD
Last Name:MUETTERTIES
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 1:11 FRIENDSHIP ST
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:RI
Mailing Address - Zip Code:02840-2271
Mailing Address - Country:US
Mailing Address - Phone:401-845-1593
Mailing Address - Fax:401-847-0650
Practice Address - Street 1:11 FRIENDSHIP ST
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:RI
Practice Address - Zip Code:02840-2271
Practice Address - Country:US
Practice Address - Phone:401-845-1593
Practice Address - Fax:401-847-0650
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2015-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD10743207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIU400167716OtherMEDICARE NGS
RI7057902Medicaid
RIH67426Medicare UPIN
RI7057902Medicaid