Provider Demographics
NPI:1821065368
Name:STOLPE, MARK M (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:M
Last Name:STOLPE
Suffix:
Gender:M
Credentials:MD
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Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:1907 S BROADWAY AVE # 101
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-4201
Mailing Address - Country:US
Mailing Address - Phone:208-345-1222
Mailing Address - Fax:208-345-1261
Practice Address - Street 1:1907 S BROADWAY AVE # 101
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-4201
Practice Address - Country:US
Practice Address - Phone:208-345-1222
Practice Address - Fax:208-345-1261
Is Sole Proprietor?:No
Enumeration Date:2006-03-03
Last Update Date:2010-02-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IDM-9741207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID80761300Medicaid
ID1134917Medicare PIN
D99863Medicare UPIN