Provider Demographics
NPI:1841219300
Name:GAETKE, MARK JONATHAN (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:JONATHAN
Last Name:GAETKE
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 1:1530 E 6TH ST
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89512-3707
Mailing Address - Country:US
Mailing Address - Phone:775-322-5757
Mailing Address - Fax:775-322-5776
Practice Address - Street 1:1530 E 6TH ST
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89512-3707
Practice Address - Country:US
Practice Address - Phone:775-322-5757
Practice Address - Fax:775-322-5776
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2009-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV6893207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVB0272ZMedicare UPIN
NVBK083AMedicare PIN
NVBK083BMedicare PIN