Provider Demographics
NPI:1376746693
Name:MARK D CETTIE
Entity Type:Organization
Organization Name:MARK D CETTIE
Other - Org Name:HIGH PLAINS PODIATRY GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:D
Authorized Official - Last Name:CETTIE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:806-354-8760
Mailing Address - Street 1:1900 S COULTER ST STE P
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79106-1795
Mailing Address - Country:US
Mailing Address - Phone:806-354-8760
Mailing Address - Fax:806-354-8792
Practice Address - Street 1:1900 S COULTER ST STE P
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79106-1795
Practice Address - Country:US
Practice Address - Phone:806-354-8760
Practice Address - Fax:806-354-8792
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-06
Last Update Date:2012-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXTX0974213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0072AXOtherBLUE CROSS BLUE SHIELD
TX0072AXOtherBLUE CROSS BLUE SHIELD
TX0072AXMedicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER