Provider Demographics
NPI:1922080621
Name:UNVERZAGT, MARK EDWARD (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:EDWARD
Last Name:UNVERZAGT
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 313
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87103-0313
Mailing Address - Country:US
Mailing Address - Phone:505-245-1670
Mailing Address - Fax:
Practice Address - Street 1:925 COAL AVE SW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-3743
Practice Address - Country:US
Practice Address - Phone:505-246-1670
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-17
Last Update Date:2011-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM91-336207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMF20195Medicare UPIN