Provider Demographics
NPI:1619914447
Name:ENGELSTAD, MARK DONALD (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:DONALD
Last Name:ENGELSTAD
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 1:3520 W 92ND AVE
Mailing Address - Street 2:SUITE #104
Mailing Address - City:WESTMINSTER
Mailing Address - State:CO
Mailing Address - Zip Code:80031-3303
Mailing Address - Country:US
Mailing Address - Phone:303-429-6600
Mailing Address - Fax:
Practice Address - Street 1:3520 W 92ND AVE
Practice Address - Street 2:SUITE #104
Practice Address - City:WESTMINSTER
Practice Address - State:CO
Practice Address - Zip Code:80031-3303
Practice Address - Country:US
Practice Address - Phone:303-429-6600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2014-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO36313207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01363134Medicaid
COC800627Medicare PIN
COG97447Medicare UPIN