Provider Demographics
NPI:1790794824
Name:MASOTTI, MARC ANTHONY (MD)
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:ANTHONY
Last Name:MASOTTI
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:PO BOX 3299
Mailing Address - Street 2:
Mailing Address - City:CARSON CITY
Mailing Address - State:NV
Mailing Address - Zip Code:89702-3299
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4401A UNION ST
Practice Address - Street 2:
Practice Address - City:JOHNSTOWN
Practice Address - State:CO
Practice Address - Zip Code:80534-2800
Practice Address - Country:US
Practice Address - Phone:801-783-5011
Practice Address - Fax:801-746-3734
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-07
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM9498207R00000X
NM94-98208M00000X
CODR.0053289208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM08639779Medicaid
1380580OtherUHC
QMP000003390487OtherMOLINA
202019599OtherPRESBYTERIAN HEALTH PLANS
NMNM002A17OtherBCBS NM
QMP000003390487OtherMOLINA
NM08639779Medicaid