Provider Demographics
NPI:1629064613
Name:LONQUIST, MARK RALPH (MD)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:RALPH
Last Name:LONQUIST
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:3815 E BELL RD STE 2200
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-2139
Mailing Address - Country:US
Mailing Address - Phone:602-633-3838
Mailing Address - Fax:602-633-3845
Practice Address - Street 1:13555 W MCDOWELL RD
Practice Address - Street 2:#103
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85395
Practice Address - Country:US
Practice Address - Phone:623-925-1157
Practice Address - Fax:623-932-1045
Is Sole Proprietor?:No
Enumeration Date:2005-09-23
Last Update Date:2019-04-18
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Provider Licenses
StateLicense IDTaxonomies
AZ22778207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ188210OtherAHCCCS
F97675Medicare UPIN
AZZ108706Medicare PIN