Provider Demographics
NPI:1760668792
Name:MAMMOTH, MARK
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:MAMMOTH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 WAHOO DRIVE
Mailing Address - Street 2:NAVAL BRANCH HEALTH CLINIC
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06349-5600
Mailing Address - Country:US
Mailing Address - Phone:860-694-2377
Mailing Address - Fax:860-694-2590
Practice Address - Street 1:1 WAHOO DRIVE
Practice Address - Street 2:NAVAL BRANCH HEALTH CLINIC
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06349-5600
Practice Address - Country:US
Practice Address - Phone:860-694-2377
Practice Address - Fax:860-694-2590
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-22
Last Update Date:2008-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman