Provider Demographics
NPI:1568491975
Name:NOOTENS, MARK THOMAS (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:THOMAS
Last Name:NOOTENS
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 1:14125 HUSEMAN ST
Mailing Address - Street 2:
Mailing Address - City:CEDAR LAKE
Mailing Address - State:IN
Mailing Address - Zip Code:46303-9316
Mailing Address - Country:US
Mailing Address - Phone:219-781-3191
Mailing Address - Fax:
Practice Address - Street 1:931 FRAN LIN PKWY
Practice Address - Street 2:
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-3540
Practice Address - Country:US
Practice Address - Phone:219-513-0107
Practice Address - Fax:219-513-0108
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2022-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01042703207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN060070754OtherRR MEDICARE PROVIDER #
IL303467487Medicaid
IN000000243924OtherANTHEM PROVIDER #
IN200043060BMedicaid
IN000000243924OtherANTHEM PROVIDER #
IN060070754OtherRR MEDICARE PROVIDER #
IN197170Medicare ID - Type Unspecified