Provider Demographics
NPI:1942331061
Name:MARK MANN, M.D., P.C.
Entity Type:Organization
Organization Name:MARK MANN, M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:KRISTI
Authorized Official - Middle Name:
Authorized Official - Last Name:BOMGREN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-323-0232
Mailing Address - Street 1:90 N 30TH ST
Mailing Address - Street 2:SUITE 4
Mailing Address - City:CLINTON
Mailing Address - State:OK
Mailing Address - Zip Code:73601-3101
Mailing Address - Country:US
Mailing Address - Phone:580-323-0232
Mailing Address - Fax:580-331-1410
Practice Address - Street 1:90 N 30TH ST
Practice Address - Street 2:SUITE 4
Practice Address - City:CLINTON
Practice Address - State:OK
Practice Address - Zip Code:73601-3101
Practice Address - Country:US
Practice Address - Phone:580-323-0232
Practice Address - Fax:580-331-1410
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2011-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK20775207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK=========001OtherBLUE CROSS BLUE SHIELD
OKOKB5167Medicare PIN