Provider Demographics
NPI:1376521740
Name:ZUBRES, MARK DAVID (DO)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:DAVID
Last Name:ZUBRES
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 1:1 ALTURA VISTA
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87507-7771
Mailing Address - Country:US
Mailing Address - Phone:417-766-7522
Mailing Address - Fax:
Practice Address - Street 1:1 ALTURA VISTA
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87507-7771
Practice Address - Country:US
Practice Address - Phone:417-766-7522
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-05
Last Update Date:2016-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR8N042085U0001X
PAOS004127L2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP00614577OtherRAILROAD MEDICARE
000092457OtherPINNACLE MEDICARE SERVICE
PA103053593Medicaid
MOP00254931OtherRAILROAD MEDICARE
211107OtherHEALTHLINK INC.
AR159670003Medicaid
MO1191801OtherBCBS OF MO
MO242912434Medicaid
1198060OtherFIRST HEALTH
PAP01594306Medicare PIN
AR159670003Medicaid
MOP00614577OtherRAILROAD MEDICARE