Provider Demographics
NPI:1578544797
Name:FRUIN, MARK E (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:E
Last Name:FRUIN
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 1:5444 S. GREEN ST.
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84123-5632
Mailing Address - Country:US
Mailing Address - Phone:801-262-8120
Mailing Address - Fax:801-262-3897
Practice Address - Street 1:5444 S. GREEN ST.
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84123-5632
Practice Address - Country:US
Practice Address - Phone:801-262-8120
Practice Address - Fax:801-262-3897
Is Sole Proprietor?:No
Enumeration Date:2005-11-07
Last Update Date:2012-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT18095512052085R0202X
UT180955-12052085N0700X
IDM-114982085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTP00255592OtherRR MEDICARE
UTP00205749OtherRR MEDICARE
ID003698900Medicaid
UT09768Medicaid
NV002089673Medicaid
WY120731800Medicaid
AZ004820Medicaid
E27903Medicare UPIN
ID003698900Medicaid
NV002089673Medicaid