Provider Demographics
NPI:1225229347
Name:SERRA, MARK (DO)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:SERRA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 LOUISIANA AVENUE
Mailing Address - Street 2:
Mailing Address - City:LIBBY
Mailing Address - State:MT
Mailing Address - Zip Code:59923
Mailing Address - Country:US
Mailing Address - Phone:406-283-7000
Mailing Address - Fax:406-293-7931
Practice Address - Street 1:350 LOUISIANA AVENUE
Practice Address - Street 2:
Practice Address - City:LIBBY
Practice Address - State:MT
Practice Address - Zip Code:59923
Practice Address - Country:US
Practice Address - Phone:406-283-7000
Practice Address - Fax:406-293-7931
Is Sole Proprietor?:No
Enumeration Date:2007-08-05
Last Update Date:2013-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIL1169747390200000X
MTMED-PHYS-LIC-12100207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program