Provider Demographics
NPI:1225222748
Name:MARK S FRALEY, D.O.,P.C.
Entity Type:Organization
Organization Name:MARK S FRALEY, D.O.,P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:S
Authorized Official - Last Name:FRALEY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:719-597-4200
Mailing Address - Street 1:2141 ACADEMY CIR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80909-1686
Mailing Address - Country:US
Mailing Address - Phone:719-597-4200
Mailing Address - Fax:719-597-4495
Practice Address - Street 1:2141 ACADEMY CIR
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-1686
Practice Address - Country:US
Practice Address - Phone:719-597-4200
Practice Address - Fax:719-597-4495
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-28
Last Update Date:2019-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO34357207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1225222748OtherNPI