Provider Demographics
NPI:1790792851
Name:GAUGHAN, MARK D (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:D
Last Name:GAUGHAN
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:523 S CAMINO DEL RIO STE B
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81303-6853
Mailing Address - Country:US
Mailing Address - Phone:970-247-1970
Mailing Address - Fax:970-259-1668
Practice Address - Street 1:523B SOUTH CAMINO DEL RIO
Practice Address - Street 2:
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81303-6853
Practice Address - Country:US
Practice Address - Phone:970-247-2970
Practice Address - Fax:970-259-1668
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2013-07-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CO37711207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO06977529Medicaid
H10047Medicare UPIN
464788Medicare ID - Type Unspecified