Provider Demographics
NPI:1437159944
Name:DEIBERT, MARK C (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:C
Last Name:DEIBERT
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 1:536 COTTONWOOD RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59718
Mailing Address - Country:US
Mailing Address - Phone:406-586-8029
Mailing Address - Fax:406-586-8009
Practice Address - Street 1:536 COTTONWOOD RD
Practice Address - Street 2:SUITE 100
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59718
Practice Address - Country:US
Practice Address - Phone:406-586-8029
Practice Address - Fax:406-586-8009
Is Sole Proprietor?:No
Enumeration Date:2005-07-26
Last Update Date:2011-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT8221207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT01458-1OtherBCBSMT
MT1194070001OtherCIGNA DME
MT0000104686Medicaid
MT01458-1OtherBCBSMT
MT000083503Medicare ID - Type Unspecified