Provider Demographics
NPI:1891923033
Name:MAURER, MARK EDWARD
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:EDWARD
Last Name:MAURER
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 1:1619 N GREENWOOD ST
Mailing Address - Street 2:STE 300
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003-2644
Mailing Address - Country:US
Mailing Address - Phone:719-543-2476
Mailing Address - Fax:719-543-2479
Practice Address - Street 1:1619 N GREENWOOD ST
Practice Address - Street 2:STE 300
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003-2644
Practice Address - Country:US
Practice Address - Phone:719-543-2476
Practice Address - Fax:719-543-2479
Is Sole Proprietor?:No
Enumeration Date:2009-06-25
Last Update Date:2012-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC006125213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO27033333Medicaid
CO27033333Medicaid