Provider Demographics
NPI:1275039554
Name:DECOTIIS, MARK (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:DECOTIIS
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 1:7500 BROOKTREE RD STE 302
Mailing Address - Street 2:
Mailing Address - City:WEXFORD
Mailing Address - State:PA
Mailing Address - Zip Code:15090-9285
Mailing Address - Country:US
Mailing Address - Phone:412-367-0600
Mailing Address - Fax:
Practice Address - Street 1:7500 BROOKTREE RD
Practice Address - Street 2:
Practice Address - City:WEXFORD
Practice Address - State:PA
Practice Address - Zip Code:15090-9254
Practice Address - Country:US
Practice Address - Phone:412-367-0600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-04
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD477420208100000X, 2081P2900X, 2081S0010X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
No2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program