Provider Demographics
NPI:1730143397
Name:DEARDEN, MARK J (DO)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:J
Last Name:DEARDEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1475
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50305-1475
Mailing Address - Country:US
Mailing Address - Phone:515-237-3985
Mailing Address - Fax:515-237-3994
Practice Address - Street 1:1540 HIGH ST
Practice Address - Street 2:SUITE 101
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50309-3106
Practice Address - Country:US
Practice Address - Phone:515-237-3985
Practice Address - Fax:515-237-3994
Is Sole Proprietor?:No
Enumeration Date:2006-04-12
Last Update Date:2014-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA3457207Q00000X
IADO-03457207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA17543OtherER GROUP #
IA2274951Medicaid
IA55965OtherVFMC GROUP #
IAI15031Medicare PIN
IAH72449Medicare UPIN
IAI11981Medicare ID - Type Unspecified